Introduction to Neuro-ophthalmology

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This is the lecture I gave today for sixth year medical students in power point format. I had to remove some of the movies to limit file size.

This is the lecture I gave today for sixth year medical students in power point format. I had to remove some of the movies to limit file size.

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  • 1. Introduction to Neuro-Ophthalmology
    • Raed Behbehani , MD FRCSC
  • 2. Neuro-ophthalmology
    • Diseases of the eye and the neurological apparatus that serves it (optic nerve and chiasm, cranial nerves, visual pathways and cortex).
    • 60% of our brain is linked to vision
    • Afferent: Optic nerve, retina, chiasm, visual pathyways, cortx.
    • Efferent: Cranial nerve III,IV,VI, ocular muscles, brain stem control centers.
  • 3. Afferent System
  • 4. Efferent System Cranial Nerves III, IV, VI Horizontal and Vertical Gaze Center Smooth Pursuit and Saccade control
  • 5. Symptoms
    • Loss of vision (transient, constant, mono- or binocular).
    • Diplopia.
    • Ptosis.
    • Visual disturbances.
    • Pupil irregularities.
    • Eyelid or Facial spasms.
  • 6. Clinical Approach
    • History is the most important part or the assessment.
    • “ Where” is the lesion ?
    • “ What” can be the lesion ?
    • Is this an emergency ?
  • 7. Diseases of the Afferent System
    • Optic neuritis
    • Ischemic optic neuropathy (Arteritic vs Non-Arteritic)
    • Other optic neuropathies (compressive, papilledme, inflammatory, heriditary).
    • Chiasmopathies.
    • Strokes causing visual field defects.
  • 8. Diseases of the Efferent System
    • Cranial Neuropathies (III, IV, VI).
    • Nystagmus.
    • Ocular Myasthenia.
    • Blepharospasm, Hemifacial Spasm.
    • Pupillary Abnormalities.
  • 9. What I can do for a patient with vision loss?
    • Before you refer, you can do a lot !
    • History : Sudden or chronic (urgency)
    • Check visual acuity (use near vision cards).
    • Check for relative afferent pupillary defect.
    • Do a visual field by confrontation.
    • Ophthalmoscopy.
  • 10. How to check for RAPD
  • 11. Visual Field by Confrontation
  • 12. Direct Ophthalmoscopy
  • 13. Optic Neuritis
    • Sudden loss of vision.
    • Pain with eye movements.
    • Females > Males.
    • RAPD present.
    • Optic disc normal.
    • MRI is important for MS risk determination.
  • 14. MRI in optic Neuritis White matter lesion predicts high risk for development of MS ( 70% over 15 years)
  • 15. Ischemic Optic Neuropathy
    • Age > 50.
    • Acute , painless , loss of vision.
    • Diabetes, hypertesnion, and hyperlipedemia.
    • RAPD present.
    • Ophthalmoscopy : disc edema +- hemorrhage.
  • 16. Ischemic optic neuropathy
  • 17. Arteritic Ischemic Optic Neuropathy
    • Patient > 60.
    • Headache, malaise, myalgia, weight loss fever, jaw claudications, and transient loss of vision.
    • ESR, CRP are high.
    • Need to start systemic steroids immediately and do then do a TA biopsy.
  • 18. Temporal Arteritis
  • 19. Retinal Artery Occlusion
    • Painless loss of vision.
    • May be preceded by Amaurosis Fugax.
    • Source of emboli usually carotid or cardiac.
    • Less common causes: Vasuclitis (GCA, Anti-phospholipid syndrome).
    • Order Carotid Doppler Study and, Echocardiography.
  • 20. Central Retinal Artery Occlusion
  • 21. Branch Retinal Artery Occlusion
  • 22. Compressive lesions
    • Slowly progressive loss of vision.
    • Can by uni-lateral or bilateral.
    • Pituitary tumors, craniopahryngiomas, and meningiomas of the skull base.
    • Require neuro-imaging (MRI) for diagnosis.
  • 23. Visual field defects
  • 24. Pituitary tumors
  • 25. Pituitary Tumors
  • 26. Homonymous Hemianopsia
  • 27. Papilledema
    • Disc edema due to raised intracranial pressure (mass, pseudotumor cerebri).
    • Headache, transient visual obscurations, Diplopia, and tinnitus.
    • Normal visual acuity and visual fields early.
    • Ophthalmoscopy.
    • Urgent CT scan of the head with contrast.
  • 28. Papilledema
  • 29. Idiopathic Intracranial Hypertension (pseudotumor cerebri)
    • Women > Men (9:1) in childbearing age.
    • 90% of affected women are obese.
    • Normal CT/MRI/MRV and CSF analysis.
    • Recent weight gain (last 6 months).
    • Medications-linked : Tetracycline for acne , oral contraceptives, insulin-like growth factors in children.
    • Aim of treatment is stop progressive loss of vision (Diuretics and Surgery).
  • 30. Diplopia
    • Key question “Is it only in one eye ?” , “ Does it go away when you close either eye ?”
    • Monocular diplopia is always refractive in origin (cataract, astigmatism).
    • Examine lids and pupils in addition to eye movement.
    • Examine all cranial nerves.
  • 31. Oculomotor Nerve Palsy
  • 32. Pupil-involving Third Nerve Palsy UrgentMRI/MRA or MRI/CTA
  • 33. Abducens Nerve Palsy
  • 34. Trochlear Neve Palsy
    • Patients complain of vertical diplopia.
    • Can present with abnormal head tilt.
    • Can be congenital or acquired.
  • 35. Trochlear Nerve Palsy - Head Tilt Test
  • 36. Cranial Neuropathies (III,IV,VI)
    • Ischemic (diabetes, hypertension and hyperlipidemia).
    • Demyelinating.
    • Compressive (tumor, aneurysm).
    • Trauma.
    • Raised ICP.
  • 37. Multiple Cranial Neuropathies (III,IV,VI)
    • Ischemic cranial neuropathies are almost always isolated.
    • If multiple simultaneous CN, suspect lesion in the posterior orbit/cavernous sinus region.
    • Usually due to mass lesion.
  • 38. Cavernous Sinus
  • 39. Ocular Myasthenia
    • Myasthenic signs restricted to the ocular muscles.
    • Fatiguable diplopia and ptosis.
    • Ice test or rest test in the clinic demonstrate improvement.
    • Acetylcholine receptor antibodies (positive in 50 % only).
    • Single fiber EMG.
  • 40. Ocular Myasthenia before ice test after ice test 2 minutes
  • 41. Pupillary Abnormalities
    • Anisocoria : Unequality of pupils size.
    • It can be accidental discovery.
    • Physiologic in 40% of patients
    • It can be isolated or associated with lid or ocular motility abnormalities.
    • Can be iatrogenic or self-induced (pharamacologic).
    • N
  • 42. Pupil Examination
    • Shine light directly at pupil (light response).
    • Test near response (miosis with accomodation).
    • Check pupil sizes and measure it in both light and dark.
    • Parasympathetic (constrict) and Sympathetic (dilate) control.
  • 43. Pupil Light Reflex
  • 44. Diagnosis ?
  • 45. Horner Syndrome
    • A defect in oculosympathetic flow to the eye (pupil does not dilate in dark).
    • Ptosis, miosis and pseudo-enophtalmos.
    • Internal carotid artery dissection, neck trauma or surgery, brain stem strokes (Wallerburg Syndrome), Apical lung tumors.
    • Urgent MRI/MRA of the head and neck for acute Horner’s Syndrome.
  • 46. Oculosympathetic Pathway
  • 47. Adies Pupil
    • Pupil is larger with light/near dissociation (pupil does not constrict well to light but does for near).
    • Can be associated with diminished deep tendon reflexes (Holmes-Adies Syndrome).
  • 48. Benign Essential Blepharospasm
  • 49. Hemifacial Spasm
  • 50. Summary
    • Neuro-ophthalmic problems of the afferent and efferent visual system are common.
    • Afferent diseases include optic nerve, chisamopathies and visual pathway diseases.
    • Efferent diseases include cranial neuropathies, pupillary abnormalities and facial spasms.
    • There is no substitute for good medical history and examination.