Download - Demystifying the Neuro-Ophthalmologic Exam
SATURDAY NOVEMBER 11, 2017
TODD M. BISHOP, DVM, DACVIM (N)
NEUROLOGY & NEUROSURGERY
UPSTATE VETERINARY SPECIALTIES
DEMYSTIFYING THE NEURO-
OPHTHALMOLOGIC EXAM
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Pupillary control
Visual pathways
Ocular movements
Eyelid innervation
Lacrimation
Anatomic localization
Case examples
LECTURE OUTLINE
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Like every reflex there is …
Sensory (Afferent) component
Motor (Efferent) component
THE PLR
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AFFERENT ARM OF PLR
R= retina
II= optic nerve
OC= optic chiasm
OT= optic tract
PTN= pretectal nucleus
LGN= lateral geniculate nucleus
PSN= parasympathetic nucleus of CN III
III= oculomotor nerve
CG= ciliary ganglion
SCN= short ciliary nerve
R
II
OC
OT
PTNLGN
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CHIASMAL DECUSSATION
Primates=50%
Feline=65%
Canine=75%
Equine, bovine, porcine=80-90%
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FATE OF THE POST-CHIASMAL OPTIC TRACT
20% of fibers synapse in PTN to complete PLR
80% of fibers synapse in LGN bound for the visualcortex
20%80%
PTNLGN
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EFFERENT ARM OF PLR
R= retina
II= optic nerve
OC= optic chiasm
OT= optic tract
LGN= lateral geniculate nucleus
PTN= pretectal nucleus
PSN= parasympathetic nucleus of CN III
III= oculomotor nerve
CG= ciliary ganglion
SCN= short ciliary nerve
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PTN
PSN
III
CG
SCN
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GEE WIZ ….
Dogs have 5-8 SCNs
Cats have 2 SCNs:
Nasal and malar branches
Only carry PSN fibers
“D-shaped” pupil
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Pupillary constriction
Parasympathetically mediated (Ach)
Pupillary dilation
Sympathetically mediated (norEpi)
IRIDIAL MUSCULATURE
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SYMPATHETIC
INNERVATION
#1
#2#3
Very uncommon!
#4
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HORNER SYNDROME
Miosis
Ptosis
Enophthalmus
Nictitans protrusion
Episcleral injection
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2.5% phenylephrine
Pupil dilation
resolution of ptosis
Retraction of nictitans
5-8 minutes
Lesion in 2nd LMN
0.001% Epinephrine
Pupillary dilation
20 minutes if 2nd LMN affected
38-40 minutes if 1st LMN affected
PHARMACOLOGIC TESTING: SYMPATHETIC
DISTURBANCES
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0.5% physostigmine
Indirect PNS
UMN lesion → rapid constriction
LMN lesion → no constriction
Normal eye → constriction w/ in 40-60 mins.
2% pilocarpine
Direct PNS
Rapid pupil constriction with either UMN or LMN lesion
Normal eye constricts w/ in 20 mins.
A rule out for iris atrophy (would not constrict)
PHARMACOLOGIC TESTING: PARASYMPATHETIC
DISTURBANCES
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Easy to see mydriasis in bright sunlight (ie. A cat in a window sill).
Easy(ish) to see miosis in the dark.
But what about asymmetric pupils in ambient room light?
Which pupil is affected?
Is one pupil too small or is the other too big?
ANISOCORIA
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If you think a pupil is too big, put a bright light into that eye and observe for complete constriction.
If you think a pupil is too small, bring the patient into the dark and observe for complete dilation.
KEEP IT SIMPLE …
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USE A BRIGHT LIGHT!
Non-
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Mydriasis
Oculomotor nucleus/nerve lesion
Iris atrophy
Glaucoma
Posterior synechia
Pharmacological blockade
Miosis
Horner syndrome
Supranuclear inhibition
Uveitis
Keratitis
Posterior synechia
ANISOCORIA
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Is there a direct response to bright light (directed into the temporal retina)
Reaction? Complete? (sluggish?)
Is there a consensual (indirect) response when light in shown in the fellow eye?
WHEN EVALUATING THE PLR
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DYNAMIC CONTRACTION
ANISOCORIA
anisocoria (direct PLR > indirect PLR)
Occurs in non-primates
due to unequal decussation of fibers
75%25%
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“positive test” occurs when illuminated eye dilates rather than constricts
“Marcus-Gunn pupil”
Unilateral retinal or optic nerve lesion
SWINGING FLASHLIGHT TEST
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PARADOXICAL PUPIL
Central chiasm lesion
Symmetric mydriasis
Direct and indirect PLR present
Indirect response > direct response !!!
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CEREBELLAR AFFECTS ON PUPILS
Fastigial lesion Contralateral mydriasis
Ipsilateral nictitans protrusion
Interpositus lesion Ipsilateral mydriasis
Contralateral nictitansprotrusion
F
L
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I
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LET’S REVIEW
Afferent Arm PLR abnormal
Vision affected
Efferent Arm PLR abnormal
Vision normal
Cortical lesion (after OT splits) PLR normal
Vision affected
R
II
OC
OT
PTNLGN
PSN
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CONSCIOUS
VISUAL PERCEPTION
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Menace response (12 weeks)
Dazzle reflex
Cotton ball drop
Visual placing reaction
Obstacle course
VISUAL ASSESSMENT
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Response NOT reflex
Closure of palpebral fissure +/- globe retraction, head turn
Puppies develops between 10-12 weeks of age
Cortically mediated response
Requires that the entire visual pathway be intact
CereBELLAR lesion may cause IPSILATERAL menace deficits WITHOUT vision loss!
MENACE RESPONSE
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MENACE RESPONSE
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a subcortically mediated “brainstem” REFELX
Palpebral fissure closes in response to bright stimulus
Lids may open then close
Ipsilateral response > contralateral response
DAZZLE REFLEX
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DAZZLE REFLEX
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OCULAR MOVEMENT CONTROL
CN III (Oculomotor) Medial rectus (adduction)
Dorsal rectus (elevation)
Ventral rectus (depression)
Ventral oblique (extortion)
CN IV (Trochlear) Dorsal oblique (intortion)
CN VI (Abducens) Lateral rectus (abduction)
Retractor bulbi (retraction)
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Vestibulo-ocular reflex (VOR)
a.k.a. Doll’s eye or oculocephalic reflex
Corneal reflex (V-VI/VII)
Resting or positional strabismus
TESTING OCULAR MOVEMENTS
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VESTIBULO-OCULAR REFLEX (VOR)
VIII→MLF →III,IV,VI
Move head horizontal to RIGHT
Smooth pursuit LEFT
Saccade beat RIGHT
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CORNEAL REFLEX (V-VI/VII)
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RESTING STRABISMUS
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Afferent innervation
Medial canthus (V-ophthalmic)
Lateral canthus (V-maxillary)
Efferent innervation
Levator palpebrae superioris (III)
Orbicularis oculi (VII)
Muller’s muscles (SNS in Voph)
* lack of input from any of these → PTOSIS
EYELID INNERVATION
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Palpebral reflex (Voph/max → VII)
Corneal reflex (Voph → VII)
Menace response (II → VII)
Dazzle reflex (II → VII)
TESTING EYELID INNERVATION
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LACRIMATION
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VII nucleus (PSN)
VII
major pertosal n.
n. of pterygoid canal
pterygopalatine ganglion
Lacrimal n. (Voph) Zygomaticotemporal n. (Vmax)
lacrimal gland
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VII → V
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Schirmer Tear Test (STT)
Tests for neurogenic KCS
Also look for xeromycteria (zē′rō-mik-tē′rē-ă)
Dry nose on the ipsilateral side
TESTING LACRIMATION SYSTEM
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Neuroparalytic keratitis Exposure keratitis due to facial (VII) paralysis Uncommon complication in dogs and cats due to presence of the
nictitans
Neurotrophic keratitis Trigeminal (V) nerve provides trophic factors necessary for corneal health denervation → epithelial degeneration and stromal edema Progressing to desiccation, neovascularization, opacification, ulceration
and even perforation Some eyes may require enucleation
NEUROGENIC KERATITIS
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Generally non-responsive to topical Cyclosporine and Tacrolimus
Oral pilocarpine therapy may be required:
Directly stimulates denervated gland
Use 2% pilocarpine eye drops as follows:
2 drops per 20 lbs body wt. BID w/ food
Inc. dose by 1-2 drops per week until toxicity (V/D) occurs, then back off one step
May require lifelong therapy
TREATING NEUROTROPHIC KCS
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Ask yourself these questions …
Is the pet BLIND (no menace)?
If so which eye?
Is there ANISOCORIA?
If so, which pupil is too big or too small?
Are the PLRs intact?
If so are they intact directly and consensually?
ANATOMIC DIAGNOSIS (ADX)
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LET’S REVIEW AGAIN!
Afferent Arm PLR abnormal
Vision affected
Efferent Arm PLR abnormal
Vision normal
Cortical lesion (after OT splits) PLR normal
Vision affected
R
II
OC
OT
PT
NLGN
PSN
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UNILATERAL LEFT RETINAL LESION
BLIND? Yes, ipsilateral (OS).
ANISOCORIA? Yes, ipsilateral mydriasis (OS)
PLRs? Light in OS → no constriction OU
Light in OD → constriction OU
* WARNING: PLRs may persist with advanced retinal disease!
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UNILATERAL LEFT OPTIC NERVE LESION
Same findings as unilateral retinal lesion
Positive swinging flashlight test
ADx: retina or optic nerve
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BLIND?
Yes, bilaterally.
ANISOCORIA?
No, but mydriasis OU.
PLRs?
Light in OS → decreased to no response OU
Light in OD → decreased to no response OU
Paradoxical pupil?
ADx: bilateral retina/optic nerve oroptic chiasm
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OPTIC CHIASM LESION
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BLIND? Yes, contralateral (OS)
ANISOCORIA? Yes, but subtle mydriasis (OS)
PLRs? Light in OS both constrict but OS
incomplete Light in OD both constrict but OS
incomplete
Swinging flashlight test is Negative
ADx: similar to retina/optic nerve but anisocoria and PLRs less affected
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UNILATERAL RIGHT OPTIC TRACT LESION
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BLIND? No, sighted OU
ANISOCORIA? Yes, mydriasis (OS)
PLRs? Light in OS, constriction OD
Light in OD, constriction OD
ADx: efferent ONLY on leftas vision not affected
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OCULAR MOTOR NERVE (NUCLEUS) LESION ON LEFT
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BLIND? Yes, contralateral (OS)
ANISOCORIA? No
PLRs? Light in OS, constriction complete
and symmetric OU
Light in OD, constriction complete and symmetric OU
ADx: lesion must be caudal to where OT splits to PTN and LGN on the right side
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UNILATERAL RIGHT CORTICAL LESION
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BILATERAL CORTICAL LESIONS
BLIND? Yes, bilaterally (OU)
ANISOCORIA? No
PLRs? Normal OU
ADx: bilateral occipital lobe
DDx: hypoxia, thiamine, lead, storage diseases
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Sig: 3-yr MI Doberman pinscher
CC: dilated left pupil
Hx: duration of 6 days
Neurologic exam:
Normal menace OU
Left pupil widely dilated in room light
Light OS – only OD constricts
Light OD – only OD constricts
No strabismus; slight ptosis & dec. adduction OS
CASE STUDY #1
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CASE STUDY #1
BLIND?
No, sighted OU
ANISOCORIA?
Yes, mydriasis (OS)
PLRs?
Only OD responds
Bonus Info:
Ptosis OS (Lev. Palp. Sup.)
↓ adduction OS (Med. Rectus)
http://www.omconcept.fr
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Anatomic Diagnosis?
left oculomotor n (III) nucleus or nerve
Definitive Diagnosis?
Germ Cell Tumor
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CASE STUDY #1
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Sig: 3-yr FI miniature poodle
CC: seizures, abnormal behavior
Hx: 5 generalized seizures over the past week; 3 day progressive lethargy w/ circling and head pressing
Neurologic exam: Profound lethargy, tends to circle to right w/ normal gait; slow
postural reactions on left side
No menace OU, w/ widely dilated pupils OU
Light OS- no response OU
Light OD- initially no response OU, then when light directly medially toward nasal retina, both pupils constrict
CASE STUDY #2
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CASE STUDY #2
BLIND?
Yes, bilaterally
ANISOCORIA?
No, but mydriasis OU
PLRs?
Only in nasal retina OD
www.pamperedpuppy.com
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CASE STUDY #2
Anatomic Diagnosis?
incomplete optic chiasm vs. bilateral optic tract
Definitive Diagnosis?
Pituitary Macroadenoma
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Sig: 8 yr. MI MIXB
CC: acting blind
Hx: Sudden onset of bumping into objects
Neurologic exam:
No menace OU
Both pupils moderately dilated in room light
Light OS – pupils constrict OU
Light OD – pupils constrict OU
Remainder of neuro exam is WNL
CASE STUDY #3
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CASE STUDY #3
BLIND?
Yes, bilaterally
ANISOCORIA?
No, but mydriasis OU
PLRs?
Intact OU
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CASE STUDY #3
Anatomic Diagnosis? bilateral retina/optic nerve >
optic chiasm
Differential Diagnosis? OPTIC NEURITIS
Pituitary Tumor
SARDS
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Sig: 3 yr. MI Collie
CC: seizures
Hx: generalized seizures monthly for past 8 months
Neurologic exam: No menace OS
Both pupils normal size/symmetry in room light
Light OS – no response OU
Light OD – pupils constrict OU
As you swing from OD to OS, OS dilates to original size. Cover OD w/ hand and OS dilates widely.
CASE STUDY #4
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CASE STUDY #4
BLIND?
Yes, blind OS
ANISOCORIA?
OS widely dilated in dark
PLRs?
Only when light in OD
Positive swinging flashlight test (OS dilates in bright light) http://www.aht.org.uk/images/retina6.jpg
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CASE STUDY #4
Anatomic Diagnosis?
left retina or optic nerve
Definitive Diagnosis?
Coloboma (Collie Eye Anomaly-CEA)
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Sig: 10 yr. FS Boxer
CC: depressed, circling
Hx: 1 month progressive Hx of depression, failure to recognize owner and circling to left
Neurologic exam: Depressed
Circling LEFT
RIGHT-sided postural reaction deficits
No menace OD
Normal pupil size, symmetry and reaction to light
CASE STUDY #5
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CASE STUDY #5
BLIND?
Yes, blind OD
ANISOCORIA?
No, symmetric pupils
PLRs?
Normal OU www.kingdomofpets.com
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CASE STUDY #5
Anatomic Diagnosis?
Left prosencephalon (forebrain)
Definitive Diagnosis?
Glial tumor
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Sig: 10 yr. MC MIXB CC: exophthalmia OS Hx: 1 month progressive history of sneezing, intermittent
epistaxis (left nares) and pain on opening jaw Neurologic exam: No menace OS widely dilated pupil OS Light OS- no response OU Light OD- only OD constricts OS difficult to retropulse
CASE STUDY #6
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CASE STUDY #6
BLIND? Yes, blind OS
ANISOCORIA? Yes, mydriasis OS
PLRs? OD constricts but only
directly
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CASE STUDY #6
Anatomic Diagnosis?
left optic (II) andoculomotor (III) nerves
Definitive Diagnosis?
Chondrosarcoma in the LEFT retrobulbar space
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First, ask yourself …
BLIND?
ANISOCORIA?
PLRs?
What is affected?
PLR and vision?
PLR only?
Vision only?
IN SUMMARY …
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Afferent Arm PLR abnormal
Vision affected
Efferent Arm PLR abnormal
Vision normal
Cortical lesion (after OT splits) PLR normal
Vision affected
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ONE LAST TIME …
R
II
OC
OT
PT
NLGN
PSN
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Michael Davidson, DVM, DACVO for providing an outline and some slides for this talk
Alexander De Lahunta, DVM, Ph.D for his spiritual guidance
Amanda Blackburn, DVM, DACVIM for assistance with image acquisition
A SPECIAL THANKS TO …
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