neuro 101

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NEURO 101

Jill Autry, O.D., R.Ph.

Eye Center of Texas, Houston

[email protected]

NEURO SYMPTOMS

Sudden or gradual vision loss/visual field loss AION, optic neuritis, compressive lesion

Transient visual obscurations

Papilledema, amaurosis fugax, migraine

Pain on eye movement Optic neuritis, sinusitis

Diplopia Cranial nerve palsy

Myasthenia gravis, multiple sclerosis, thyroid disease

Orbital tumor

Headache

NEURO SIGNS

APD (Afferent Pupillary Defect)

Visual field defects

Ptosis

Ocular motility restriction Optic nerve edema/pallor

Pupil abnormalities

Nystagmus

Proptosis

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Transient Visual Obscurations

Unilateral Amaurosis fugax

Associated carotid disease

Giant cell arteritis

Bilateral

Vertebrobasilar artery insufficiency

Unilateral or Bilateral

Papilledema (lasting seconds)

Migraine (lasting 10-20 minutes)

AMAUROSIS FUGAX

Unilateral vision loss of seconds to minutes toone hour

Sectoral or total darkening of vision

Ocular exam usually normal

May see arteriolar emboli

May see signs of Ocular Ischemic Syndrome Retinal hemorrhages

NVI

NVD

NVE

WORK-UP FOR AMAUROSIS

Carotid doppler

CBC with differential and Platelets Rule out hypercoagulable causes

HbA1C and Fasting Blood Glucose (FBG)

Lipid profile Not just total cholesterol

ECHO

Any signs/symptoms of Giant Cell? Order ESR (sed rate), C-reactive protein, and platelet

count immediately

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Edward C. Wade, M.D. Ting Fang-Suarez, M.D.

Chris Allee, O.D. Gurpreet Singh, M.D.

Jill Autry, O.D. Randy Reichle, O.D.

6565 West Loop South 4415 Crenshaw Rd.Bellaire, TX 77401 Pasadena, TX 77504

Phone (713)797-1010 Phone (281)998-3333

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NAME Kathy Summers AGE

ADDRESS_____________________________________________________DATE 6-27-07___

Rx Carotid doppler, CBC w/diff, platelets, HbA1C, FBG,

Lipid profile, ECHO

Dx: Amaurosis fugax

REFILLS-- Jill Autry




6565 West Loop South 4415 Crenshaw Rd.

Bellaire, TX 77401 Pasadena, TX 77504

Phone (713)797-1010 Phone (281)998-3333

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ADDRESS_____________________________________________________DATE 6-27-07___

Rx ESR, C-reactive protein, platelets

Dx: Giant cell arteritis


PTOSIS

Levator dehiscence

Post-surgical

Congenital

Myasthenia gravis Horners Syndrome

Third nerve palsy

Pseudoptosis

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PUPILS

RAPD

Relative Afferent Pupillary Defect

Use brightest light possible

Make room as dark as possible

No bilateral APD

Reverse APD when one pupil is non-functioning

Optic nerve disease

Severe retinal disease

CRVO, CRAO, Large RD

ANISOCORIA

Physiologic

Same size in light and dark

Usually less than 1mm size difference

Small pupil

Size difference greater in dark

Large pupil

Size difference greater in light

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Mydriatic Testing of Horners

Fail to dilate with cocaine 10%solutionHORNERs Fail to dilate with hydroxyamphetamine 1%POSTGANGLIONIC

Work up either way MRI of Brain and Neck

CT chest

CBC with differential

MRA

Others

ARGYLL ROBERTSON

Light-Near dissociation

Little response to light

Normal response to near

o pup s even ua y a ec e Neurosyphillis

Order RPR, FTA-ABS

Other light-near dissociations

Therefore, also order MRI

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LARGE PUPIL

Adies Tonic pupil Torn iris sphincter (history of blunt trauma)

Mydriatic drop

Posterior communicating artery aneurysm

(PCA)

Scopolamine patch

ADIES TONIC PUPIL

Usually young female

Poor reaction to light

Slow constriction to near

Slow redilation following near constriction

Vermiform movement

Constricts to 0.125%pilocarpine

Long standing can result in small pupil

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Before and after 0.125%Pilocarpine

PUPIL SHOW

. .

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BENIGN EPISODIC

UNILATERAL MYDRIASIS

Usually young women 20-40 yo

1-12 hours duration

Up to 2-3times a month

Probably migraine related

Still recommend MRI/MRA






Phone (713)797-1010 Phone (281)998-3333

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ADDRESS_____________________________________________________DATE 6-27-07___

Rx MRI and MRA of brain with and without contrast

Dx: Dilated pupil OD


NYSTAGMUS

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NYSTAGMUS

Early onset Usually pendular

90%related to vision loss

Aniridia

ROP

Optic nerve hypoplasia

Coloboma

Acquired






Phone (713)797-1010 Phone (281)998-3333

--------------------------------------------------------------------------------------------------------------------------


ADDRESS_____________________________________________________DATE 6-27-07___

Rx MRI of brain with and without contrast

Dx: Acquired nystagmus


Medication Induced Nystagmus

Benzodiazepines

ex. Valium, Xanax, Klonopin

Lithium

Dilantin (phenytoin)

Other anticonvulsants and sedatives ex. Phenobarbital, Neurontin, Carbamazepine

Alcohol intoxication

ADHD medications

ex. Adderall, Concerta, Cyclert

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DIPLOPIA

DIPLOPIA

Binocular vs. Monocular

Intermittent vs. Constant

How long since first noticed?

Worse in certain gaze?

Worse in am or pm?

Any recent head trauma?

Worse at distance or near?

Get MRI / CT of brain and orbits.

3rd NERVE PALSY

Diplopia-Horizontal with or without vertical

component

Ptosis Classic-Down and out presentation

May or may not have pupil involvement

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3rd Nerve Pupil Testing

Pupil involving Dilated pupil; minimally reactive to light

MRA with MRI

Pupil Sparing

Pupil equal in size to other eye

Normal light reaction

Ischemic microvascular disease

4th NERVE PALSY

Vertical diplopia

Head tilt towards unaffected side to decrease oreliminate diplopia

Trauma most common, then ischemic,,

Tumor rare

Parks3Test Hypertropia, worse in opposite gaze, worse in same

side head tilt

Right, left, right

Left, right, left

PARKS THREE STEP

www.e edock.com

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6th NERVE PALSY

Horizontal diplopia Worse in temporal gaze of affected eye

Decreased diplopia in gaze away from

affected eye

Commonly vasculopathic

Also seen with trauma or increased

intracranial pressure

Uncommon MS, tumor, Giant cell

MULTIPLE NERVE PALSIES

Consider cavernous sinus disease

Especially if associated with facial pain ornumbness (5th cranial nerve involvement)

Cavernous sinus houses cranial nerves 3,4,5(5a portion), and 6

Carotid-cavernous fistula

Cavernous sinus thrombosis

Metastatic tumors

MRI of brain with special attention to

cavernous sinus

7th NERVE PALSY

Unilateral facial nerve paralysis

Inability to close lid

Inability to smile on affected side

No diplopia

Start Valtrex 1 gram tid or other high doseantiviral

Manage corneal exposure

Bells Palsy

Diagnosis of exclusion

Order MRI of brain with special attention to 7th nerve

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MULTIPLE SCLEROSIS

Female >Male 18-45years old

Intermittent diplopia (usually 4th nerve)

Optic neuritis

Nystagmus

Tingling or numbness in extremities

Uhtoffs sign Worsening vision with increased body temperature

Lhermittes sign Shock-like sensation with neck flexion

OPTIC NEURITIS

Decreased vision over days

Unilateral

Pain on eye movements

+RAPD

Visual field defects vary

Swollen disc or retrobulbar

MRI of Brain and Orbits with Flair sequencing

OPTIC NEURITIS

TREATMENT TRIAL (ONTT)

Recommends treatment with IVmethylprednisolone x 3days

treatment with IV (10-14days)

Hastens visual recovery but not final visualoutcome

Prolongs time to development of MS

Do not use oral steroids alone

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DIAGNOSING

MULTIPLE SCLEROSIS

MRI of brain with Flair testing

Inspection of CSF for oligoclonal bands

Inspection of CSF for increased IgG index

VER testing shows increased latency

Neurologist

NEURORETINITIS

Initially appears as optic neuritis

May have vitreous cells and retinal whitelesions

Over days to weeks, a macular star willform

Sometimes partial, sometimes complete

Commonly associated with cat-scratchdisease or other infectious etiology

MYASTHENIA GRAVIS

Ptosis

Intermittent diplopia

Younger women; older men

Worse at end of day or with fatigue Ask about difficulty swallowing or

breathing

Check for increased ptosis with fatigue

Check orbicularis muscle function

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DIAGNOSING MYASTHENIA

MRI of Brain and Orbits

Tensilon test

Ice-test Poor mans Tensilon test

Acetylcholine receptor antibodies

Thyroid panel

Arteritic Ischemic Optic Neuropathy

AKA Giant Cell

Sudden, painless vision loss (CF or worse)

Chalky white, swollen ONH

+RAPD

Sometimes associated 6th nerve palsy

Patient >50 yo, poor health

Unilateral progressing to bilateral

Headache, jaw claudication, scalp tenderness,muscle/joint aches, weight loss, fever

IS IT GIANT CELL?

Sed rate

Normal values

Men age 2

omen age+

C-Reactive protein

Platelets

Temporal artery biopsy

If positive treat with systemic steroids

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NON-ARTERITIC ISCHEMIC

OPTIC NEUROPATHY

Sudden, painless loss of vision

With or without ONH swelling

Unilateral n y occas ona y progresses o a era

+RAPD

Visual field defect Usually altitudinal

Patients often have vasculopathic conditions Diabetes, hypertension, hyperlipidemia

Patients often have a disc at risk

AMIODARONE

OPTIC NEUROPAHTY

Optic neuropathy secondary to decreased

axoplasmic flow

Resultin o tic nerve edema

Seen within weeks of initiation of drug

Discontinue use

Can mimic NAION

Visual acuity less affected than NAION

Edema takes longer to resolve than NAION

Amiodarone-InducedOpticNeuropathy Non-ArteriticAION

OnsetofvisuallossInsidious

(months)

Rapid

(days to weeks)Degreeofvisionloss

20/20 to 20/200 20/20 to NLP

OcularinvolvementUsually

simultaneous

Rarely

simultaneousResolutionofdiscedema

Within months Within weeks

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VIAGRA

OPTIC NEUROPATHY

Non-arteritic ischemic optic neuropathy

Reported within hours of Viagra use

Association now labeled possible

No clear mechanism of action or true time

association has been established

PAPILLEDEMA SIGNS

Bilateral ONH swelling caused by

increased intracranial pressure

Peripapillary swollen NFL

Blurring of disc margins

Blurring of ONH vasculature

Peripapillary flame shaped hemorrhages

Enlarged blind spots on VF testing

No RAPD

PAPILLEDEMA SYMPTOMS

Transient obscurations of vision lasting

seconds (usually bilateral)

Headaches worse u on wakenin

Diplopia secondary to 6th nerve palsy

Little or no vision loss

*unless chronic

Color vision intact

*unless chronic

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BURIED NERVE DRUSEN

Little or no cupping

Vasculature radiates from center of disc

siblings

With age, drusen start to appear on

surface

B-scan shows buried drusen

OCT shows blank areas

UNILATERAL

ORBITAL DISEASE

Unilateral proptosis

Unilateral visual field defect

Unilateral decreased acuity

APD

MRI of brain and orbits

Optic nerve gliomas, meningiomas,

lypmphomas, cavernous hemangiomas,

mucoceles, infection, inflammation

OPTIC NERVE PIT

Congenital malformation of the optic nerve

Mostly temporal, small grayish-white defect in

the optic nerve

Can develop serous retinal detachment Usually macular due to temporal pit location

Patient will develop decreased vision with

metamorphopsia

Slight hyperopic shift with serous detachment

Recommend laser as prophylactic treatment

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VISUAL FIELD DEFECTS

Unilateral Altitudinal

AION

Optic neuritis

Tumor compression

Optic nerve head drusen

Varying defects Optic neuritis

Tumor compression

Optic nerve drusen


Bilateral

Binasal

Compression of both optic nerves; glaucoma

Pituitary tumor or other chiasmal lesion

Blind spot enlargement

Papilledema, ONH drusen, Myelinated NFL


Bilateral

Homonymous hemianopsia Stroke and trauma

Superior quadranopsia

Temporal lobe-Pie in the sky tumor more common; also stroke

Inferior quadranopsia Parietal lobe-Pie on the floor

Stroke more common; tumor less likely

Macular sparing Occipital lobe

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HEADACHES

Sinus headache

Headache often discussed with eye doctors

Pressure around eyes

Headache worse when bending over or lying

down

History of seasonal allergies or recent cold

Recommend nasal sprays/decongestants

HEADACHES

Tension headache

Most common headache

Diffuse pain like a band encircling the head

Also have pain at the back of neck and base

of skull

MIGRAINES

Women>Men;3:1

Generally starts before 20 years of age

Often have family history

May have nausea and vomiting, fatigue,

photophobia Headaches predominantly on same side;may

occasionally switch sides

Headache triggers-Stress -Chocolate -BC pills

-Bright lights -Alcohol -Pregnancy

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MIGRAINE RELATED AURA

Flashing lights, heat waves, jagged

objects, tunnel vision, colored spots

May or may not be accompanied by HA

Acephalic migraine

History of migraine is common

CLUSTER HEADACHES

Unilateral

Very painful

Typically affects men

Lasts minutes to hours; typically occurs at

same time each day

May disappear as easily as they appeared

May see ipsilateral tearing, rhinorrhea,

Horners

HEADACHES OF CONCERN

Associated with any of the following:

Scalp tenderness, weight loss, pain withchewing, ONH swelling, fever, change inbehavior, stiff neck

No history of headaches More severe headache than usual

A headache always in the same location

A headache which awakens the patient

Aura follows headache

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THYROID EYE DISEASE

Pseudoptosis Proptosis

Lid retraction

Inferior rectus-most often affected first

Medial rectus

Superior rectus

Lateral rectus

Do CT of orbits rather than MRI for thyroid

NEURO WEB SITES

www.eyedock.com

Parks3test

www.richmondeye.com

u p e n erac ve presen a ons

www.mrcophth.com/eyeclipartchua/pupils.

html

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