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NEURO-OP
Howard R Krauss, MD
Neuro-ophthalmology
Strabismus
Orbital Surgery
www.PacificSpecialists.com
5/24/2017
… NOTHING TO DISCLOTHES …
Howard R Krauss, MD
Los Angeles, CA
NEURO-OP
Pacific Eye & Ear
Howard R Krauss, MD
11645 Wilshire Blvd., Suite 600
Neuro-ophthalmology
Strabismus
Los Angeles, Ca. 90025
Orbital Surgery
310-477-5558
[email protected]
www.PacificSpecialists.com
www.PacificSpecialists.com
5/24/2017
PACIFIC EYE & EAR
Pacific Eye & Ear is an association of
eleven doctors, providing medical and
surgical services encompassing
Ophthalmology, ENT, Facial Plastic Surgery
and Audiology.
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5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
1) Talk with and examine the patient
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5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
When the vision is subnormal, proceed to:
2) Pinhole acuity
3) Refraction
4) Visual field assessment
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5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If corrected acuity is normal and visual field is normal:
1) Complete the general examination and if all
else is normal, proceed to discussion of optical
services, from spectacles to contact lenses to
surgery.
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5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If corrected acuity is abnormal or
visual field is abnormal:
1) Proceed with Retinal Evaluation
and/or consultation.
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5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If Retinal Consultant detects abnormalities and
arranges treatment for same:
1) Re-evaluate patient to assess whether or
not the retinal abnormalities are likely the only
source of the patient’s complaints.
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5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea,
crystalline lens, lens implant and posterior
capsule as potential sources of reduced
acuity;
2) Reassess the visual field reliability and pattern of abnormality
3) Assess relative light and color brightness and check for RAPD
4) Assess the optic nervehead appearance and (a)symmetry
5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG
7) Consider Neuro-ophthalmologic consultation.
www.PacificSpecialists.com
5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity;
2) Reassess the visual field reliability and
pattern of abnormality
3) Assess relative light and color brightness and check for RAPD
4) Assess the optic nervehead appearance and (a)symmetry
5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG
7) Consider Neuro-ophthalmologic consultation.
www.PacificSpecialists.com
5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity;
2) Reassess the visual field reliability and pattern of abnormality
3) Assess relative light and color
brightness and check for RAPD
4) Assess the optic nervehead appearance and (a)symmetry
5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG
7) Consider Neuro-ophthalmologic consultation.
www.PacificSpecialists.com
5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity;
2) Reassess the visual field reliability and pattern of abnormality
3) Assess relative light and color brightness and check for RAPD
4) Assess the optic nervehead
appearance and (a)symmetry
5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG
7) Consider Neuro-ophthalmologic consultation.
www.PacificSpecialists.com
5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity;
2) Reassess the visual field reliability and pattern of abnormality
3) Assess relative light and color brightness and check for RAPD
4) Assess the optic nervehead appearance and (a)symmetry
5) Consider RNFL and RGC layer
thickness analyses
6) Consider ERG
7) Consider Neuro-ophthalmologic consultation.
www.PacificSpecialists.com
5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity;
2) Reassess the visual field reliability and pattern of abnormality
3) Assess relative light and color brightness and check for RAPD
4) Assess the optic nervehead appearance and (a)symmetry
5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG
7) Consider Neuro-ophthalmologic consultation.
www.PacificSpecialists.com
5/24/2017
DIAGNOSTIC APPROACHES TO REDUCED VISION
If Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity;
2) Reassess the visual field reliability and pattern of abnormality
3) Assess relative light and color brightness and check for RAPD
4) Assess the optic nervehead appearance and (a)symmetry
5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG
7) Consider Neuro-ophthalmologic
consultation.
www.PacificSpecialists.com
5/24/2017
OCULAR COHERENCE TOMOGRAPHY (OCT)
NEURO-OPHTHALMIC APPLICATIONS
 Evaluation
and Monitoring:

MS / Optic Neuritis

Ischemic Optic Neuropathy

Any Optic Neuropathy

Compressive Optic Neuropathy

Papilledema
55-YEAR-OLD
WOMAN
WITH MS
BCVA 20/30 OD
20/25 OS
 Aware
of diminishing vision of the left
eye over 1 year, rapidly worsening over
the last 3 months.
 Intermittent
when flying.
mild pain OS, especially
47-YEAR-OLD HAWAIIAN WOMAN
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 No
proptosis
 No
enophthalmos
 No
hyper- or hypoglobus
 Orthophoric
 Full
 2+
ductions
RAPD OS
VISUAL ACUITY 20/25 OD
20/50-1 OS
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in all positions
HUMPHREY 10-26-11
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OCTOPUS 12-27-11
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RNFL THKNS 106 OD, 93 OS
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TRANSNASAL IMAGE-GUIDED
ORBITAL SURGERY (TIGOS)
TIGOS has been carried out by
Drs. Krauss & Griffiths since
2001.
The work was presented at the
5th International Congress of
the World Federation of Skull
Base Societies in 2008.
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5/24/2017
OUTPATIENT SURGERY
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IMAGE-GUIDED ENDOSCOPIC SX
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PRE-OP / OCTOPUS / POST-OP
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POST-OP
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2 WEEKS POST-OP
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
UCVA 20/25

Trace RAPD OS

Mild weakness of left adduction
and infraduction – improving dayby-day
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MRI OF THE VISUAL AFFERENT SYSTEM
Brain
and Orbits with and
without contrast
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5/24/2017
MRI OF THE VISUAL AFFERENT SYSTEM
If
you know the lesion is
retrogeniculate:
Brain
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with and without contrast
5/24/2017
MRI OF THE VISUAL AFFERENT SYSTEM
If
you know the lesion is anterior
visual pathway:
Orbits
and pituitary with and
without contrast
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5/24/2017
BSB 54yo female
11/05: Puffiness OS
Va 20/15,20/25
Ext: H 16/21
P: 1.2log LAPD
EOM: min ↓ L elev
BSB – W/U
OCT NFL (11/05):
BSB – W/U
MRI (12/05):
BSB – F/U
MRI (5/06):
BSB – F/U
10/06: Diplopia in
right gaze
Va 20/20 OU
Ext: H 16/14
EOM: min ↓ L add
P: .3log LAPD
BSB – W/U
OCT NFL (10/06):
JWD 63yo male
3/06: ↓Va OS
Va 20/20,20/60
P: .9log LAPD
JWD – POH
12/05: Routine check vision
Dx: “cataracts”
Referred for cataract extraction
Ophthalmologist said “no cataract”
JWD – W/U
OCT:
JWD – F/U
8/07: “No Δ”
Va 20/25 OU
P: .9log LAPD
JWD – W/U
OCT NFL (8/07):
KH 48yo female
11/08: ↓Va
Va 20/30,8/200
VF:
Ext: w/q
P: .3log LAPD
EOM: full
SLE: wnl
Fundus: nl DMV
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5/24/2017
KH – PMH
1/08: Polydipsia
4/08: Amenorrhea
10/08: HA, N/V
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5/24/2017
KH – W/U
OCT NFL (11/08):
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5/24/2017
KH – W/U
MRI (11/08):
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5/24/2017
KH – Rx
11/08: Transphenoidal endoscopic decompression
Path: craniopharyngioma
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5/24/2017
KH – F/U
8/09: “Better”
Va 20/20 OU
N 3pt OU
VF:
Ext: w/q
P: w/o APD
EOM: full
SLE: wnl
Ta: 19/22
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Fundus:
5/24/2017
KH – W/U
OCT NFL (8/09):
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5/24/2017
IN SUMMARY:
 Listen
to the patient and solicit information.
 Examine
the patient: determine BCVA and assess VF.
 Understand
and explain symptoms and findings.
 Consider
and recommend additional testing, or
consultation, as indicated.
 Follow-up
 Avoid
on all tests and consultations with patient.
contributing to a delay in diagnosis and treatment.
NEURO-OP
Pacific Eye & Ear
Howard R Krauss, MD
11645 Wilshire Blvd., Suite 600
Neuro-ophthalmology
Strabismus
Los Angeles, Ca. 90025
Orbital Surgery
310-477-5558
[email protected]
www.PacificSpecialists.com
www.PacificSpecialists.com
5/24/2017