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