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Transcript
Neuro-ophthalmology Abdulrahman Al-Muammar College of Medicine King Saud University Neuro-ophthalmology Objectives: • Recognize and interpret the common signs and symptoms of neuro-ophthalmic disorders Obtain appropriate history Measure visual acuity Examine pupillary reaction Test the function of the extraocular muscles Evaluate the visual fields Inspect the optic nerve head Neuro-ophthalmology Pupil Ocular motor system Visual system Visual fields Common neuro-ophthalmic disorders Pupil Pupillary size is determined by number of factors including Age Level of alertness Level of retinal illumination Accommodative effort Pupil Anatomy of pupillary pathway Afferent limb Efferent limb • Parasympathetic pathway • Sympathetic pathway Near response Pupil Pathway of pupillary reaction to light Sympathetic pathway Afferent pupillary defect (APD) Afferent pupillary defect (APD) Causes of APD Optic nerve disease Significant retinal disease Amblyopia Efferent pupillary defect Anisocoria Anisocoria Anisocoria Pupillary inequality greatest In bright light In dim light (large pupil) (small pupil) 3rd nerve palsy Ptosis Trauma Horner syndrome Tumor Physiological Temporal lobe herniation Aneurysm No 3rd nerve palsy Drug induced Adie’s pupil Iris damage (trauma/surgery/laser) Basal meningitis Anisocoria Horner syndrome Ocular motor system Ocular motor system Ocular motor system 3rd nerve palsy + ve pupillary involvement An incomplete III palsy which progress Other neurological signs No resolution in 3 months Aberrant regeneration appears Emergency Do MRI,MRA If negative do catheter angiography To r/o compressive lesion: aneurysm, tumor Other possible causes : vasculopathy, trauma, inflammatory, demyelination, infectious, MG, congenital Ocular motor system 4th nerve palsy Most frequent cause is trauma If no trauma, isolated 4th nerve palsy then most likely vasculopathic ( Do BP, BS) +ve trauma, any other neurological signs, normal BP/BS or palsy lasting > 3 months then MRI is needed. Ocular motor system 6th nerve palsy Isolated 6th nerve palsy most likely vasculopathic ( do BP/BS) Normal BP/BS, other neurological signs, trauma, or palsy > 3 months then do MRI Visual system Visual system Visual system Visual fields defect Visual fields defect Visual fields defect Visual fields defect Visual fields defect Visual fields defect Optic disc Disc swelling Mechanical signs Elevation Blurred margins Peripapillary edema Choroid folds Vascular signs Hyperemia Venous dilation Disc hemorrhage NFL infarcts Exudates Causes of disc swelling Increased intracranial pressure Ischemic optic neuropathy Optic neuritis Central retinal vein occlusion Nutritional optic neuropathy Toxic optic neuropathy ETOH-ethanol-DigitalisEthambutol -ChloramphenicolINH Tumor Infiltrative Orbital Pseudotumor Thyroid orbitopathy Amaurosis Fugax Transient monocular visual loss or dimming May last from 2-3 minutes to 30 minutes or more Due to decrease blood flow to the eye Causes: • Carotid atheroma • Cardiac valvular disease • Atrial myxoma • Retinal migraine • Giant cell arteritis • Hyperviscousity syndromes Myasthenia Gravis (MG) Chronic auto-immune disorder characterized by presence of antibodies which block the ACH receptor sites It can affect any muscle Eye signs are the presenting signs in 50% of the patients • • • • Ptosis Any ocular motility disturbances INO Variability is the hallmoark Myasthenia Gravis (MG) Diagnosis • • • • • • • • Clinically Pharmacologically (Tensilon test) Serologically Sleep test Ice-pack test CT chest Thyroid function test ANA Treatment • • • • • Acetylcholinesterase inhibitors Steroid Immunosuppressant Plasmapheresis Thymectomy Multiple sclerosis Patients with multiple sclerosis (MS) frequently have visual complaints Cerebellar dysfunction Motor symptoms Sensory symptoms Mental changes Sphincter disturbances Multiple sclerosis Ocular complications: Optic neuritis Chiasmal and retro chiasmal abnormalities Ocular motility disturbances Treatment Steroid Interferon Thank you