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Neuro-ophthalmologyNeuro-ophthalmology
Abdulrahman Al-MuammarAbdulrahman Al-Muammar
College of MedicineCollege of Medicine
King Saud UniversityKing Saud University
Neuro-ophthalmologyNeuro-ophthalmology
Objectives:Objectives:• Recognize and interpret the common signs and Recognize and interpret the common signs and
symptoms of neuro-ophthalmic disorderssymptoms of neuro-ophthalmic disorders
Obtain appropriate historyObtain appropriate history
Measure visual acuityMeasure visual acuity
Examine pupillary reactionExamine pupillary reaction
Test the function of the extraocular musclesTest the function of the extraocular muscles
Evaluate the visual fieldsEvaluate the visual fields
Inspect the optic nerve headInspect the optic nerve head
Neuro-ophthalmologyNeuro-ophthalmology
PupilPupil
Ocular motor systemOcular motor system
Visual systemVisual system
Visual fieldsVisual fields
Common neuro-ophthalmic disordersCommon neuro-ophthalmic disorders
PupilPupil
Pupillary size is determined by number Pupillary size is determined by number of factors includingof factors including
AgeAge
Level of alertnessLevel of alertness
Level of retinal illuminationLevel of retinal illumination
Accommodative effortAccommodative effort
PupilPupil
Anatomy of pupillary pathwayAnatomy of pupillary pathwayAfferent limbAfferent limb
Efferent limbEfferent limb• Parasympathetic pathwayParasympathetic pathway• Sympathetic pathwaySympathetic pathway
Near responseNear response
PupilPupil
Pathway of pupillary reaction to lightPathway of pupillary reaction to light
Sympathetic pathwaySympathetic pathway
Afferent pupillary defect (APD)Afferent pupillary defect (APD)
Afferent pupillary defect (APD)Afferent pupillary defect (APD)
Causes of APDCauses of APD
Optic nerve diseaseOptic nerve disease
Significant retinal diseaseSignificant retinal disease
AmblyopiaAmblyopia
Efferent pupillary defectEfferent pupillary defect
AnisocoriaAnisocoria
AnisocoriaAnisocoria
AnisocoriaAnisocoriaPupillary inequality greatest
In bright light(large pupil)
In dim light(small pupil)
3rd nerve palsyTraumaTumorTemporal lobe herniationAneurysm
No 3rd nerve palsyDrug inducedAdie’s pupilIris damage (trauma/surgery/laser)Basal meningitis
PtosisHorner syndrome
Physiological
AnisocoriaAnisocoria
Horner syndromeHorner syndrome
Ocular motor systemOcular motor system
Ocular motor systemOcular motor system
Ocular motor systemOcular motor system
33rdrd nerve palsy 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 systemOcular motor system
44thth nerve palsy nerve palsy
Most frequent cause is traumaMost frequent cause is trauma
If no trauma, isolated 4If no trauma, isolated 4thth nerve palsy nerve palsy then most likely vasculopathic ( Do BP, then most likely vasculopathic ( Do BP, BS)BS)
+ve trauma, any other neurological +ve trauma, any other neurological signs, normal BP/BS or palsy lasting > 3 signs, normal BP/BS or palsy lasting > 3 months then MRI is needed.months then MRI is needed.
Ocular motor systemOcular motor system
66thth nerve palsy nerve palsy
Isolated 6Isolated 6thth nerve palsy most likely nerve palsy most likely vasculopathic ( do BP/BS)vasculopathic ( do BP/BS)
Normal BP/BS, other neurological signs, Normal BP/BS, other neurological signs, trauma, or palsy > 3 months then do trauma, or palsy > 3 months then do MRIMRI
Visual systemVisual system
Visual systemVisual system
Visual systemVisual system
Visual fields defectVisual fields defect
Visual fields defectVisual fields defect
Visual fields defectVisual fields defect
Visual fields defectVisual fields defect
Visual fields defectVisual fields defect
Visual fields defectVisual fields defect
Optic discOptic disc
Disc swellingDisc swelling
Mechanical signsMechanical signsElevationElevationBlurred marginsBlurred marginsPeripapillary edemaPeripapillary edemaChoroid foldsChoroid folds
Vascular signsVascular signsHyperemiaHyperemiaVenous dilationVenous dilationDisc hemorrhageDisc hemorrhageNFL infarctsNFL infarctsExudatesExudates
Causes of disc swellingCauses of disc swelling
Increased intracranial pressureIncreased intracranial pressureIschemic optic neuropathyIschemic optic neuropathyOptic neuritisOptic neuritisCentral retinal vein occlusionCentral retinal vein occlusionNutritional optic neuropathyNutritional optic neuropathyToxic optic neuropathyToxic optic neuropathy ETOH-ethanol-Digitalis-ETOH-ethanol-Digitalis- Ethambutol -Chloramphenicol-Ethambutol -Chloramphenicol- INHINH
TumorTumorInfiltrativeInfiltrativeOrbital PseudotumorOrbital PseudotumorThyroid orbitopathyThyroid orbitopathy
Amaurosis FugaxAmaurosis FugaxTransient monocular visual loss or dimmingTransient monocular visual loss or dimming
May last from 2-3 minutes to 30 minutes or moreMay last from 2-3 minutes to 30 minutes or more
Due to decrease blood flow to the eyeDue to decrease blood flow to the eye
Causes:Causes:• Carotid atheromaCarotid atheroma• Cardiac valvular diseaseCardiac valvular disease• Atrial myxomaAtrial myxoma• Retinal migraineRetinal migraine• Giant cell arteritisGiant cell arteritis• Hyperviscousity syndromesHyperviscousity syndromes
Myasthenia Gravis (MG)Myasthenia Gravis (MG)
Chronic auto-immune disorder characterized by Chronic auto-immune disorder characterized by presence of antibodies which block the ACH presence of antibodies which block the ACH receptor sitesreceptor sites
It can affect any muscleIt can affect any muscle
Eye signs are the presenting signs in 50% of the Eye signs are the presenting signs in 50% of the patientspatients
• PtosisPtosis• Any ocular motility disturbancesAny ocular motility disturbances• INOINO• Variability is the hallmoarkVariability is the hallmoark
Myasthenia Gravis (MG)Myasthenia Gravis (MG)
DiagnosisDiagnosis• ClinicallyClinically• Pharmacologically (Tensilon test)Pharmacologically (Tensilon test)• SerologicallySerologically• Sleep testSleep test• Ice-pack testIce-pack test• CT chestCT chest• Thyroid function testThyroid function test• ANAANA
TreatmentTreatment• Acetylcholinesterase inhibitorsAcetylcholinesterase inhibitors• SteroidSteroid• ImmunosuppressantImmunosuppressant• PlasmapheresisPlasmapheresis• ThymectomyThymectomy
Multiple sclerosisMultiple sclerosis
Patients with multiple sclerosis (MS) Patients with multiple sclerosis (MS) frequently have visual complaintsfrequently have visual complaints
Cerebellar dysfunctionCerebellar dysfunction
Motor symptomsMotor symptoms
Sensory symptomsSensory symptoms
Mental changesMental changes
Sphincter disturbancesSphincter disturbances
Multiple sclerosisMultiple sclerosis
Ocular complications:Ocular complications:Optic neuritisOptic neuritis
Chiasmal and retro chiasmal abnormalitiesChiasmal and retro chiasmal abnormalities
Ocular motility disturbancesOcular motility disturbances
TreatmentTreatmentSteroidSteroid
InterferonInterferon
Thank youThank you