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NEUR
OPHTHALM O LOGY
Prepared by
Nur Hanisah Binti Zainoren
OBJECTIVES
Anatomy of the visual
pathway
Lesions of the visual
pathway
Pupillary reflexes and
their abnormalities
Anisocoria
VISUAL PATHWAY
CONSISTS OF:
OPTIC NERVES
VISUAL PATHWAY
CONSISTS OF:
The fibres of optic nerve originate in
the retina - divided into the temporal &
nasal halves of the fovea centralis.
Join the optic chiasma at the
anterolateral angle
OPTIC NERVES
OPTIC CHIASMA
VISUAL PATHWAY
CONSISTS OF:
A flat band-like structure lying above the
pituitary fossa
In the optic chiasma, there is semi-
decussation of the nerve fibres
• Nerve fibres from the nasal side of
each retina CROSS-OVER to the
opposite side
• Nerve fibres from the temporal side of
DO NOT CROSS but pass into optic
tracts of the same side
OPTIC NERVES
OPTIC CHIASMA
OPTIC TRACTS
VISUAL PATHWAY
CONSISTS OF:
Originate from the postero-lateral angle of
the optic chiasma
Cylindrical bands running outwards &
backwards to end in the lateral geniculate
bodies
They consist of the temporal fibres of the
same side and the nasal fibres of the
opposite side
OPTIC NERVES
OPTIC CHIASMA
OPTIC TRACTS
LAT. GENICULATE BODIES
VISUAL PATHWAY
CONSISTS OF:
Oval structures situated at the
posterior end of the optic tracts
The fibres of the optic tracts end in
the lateral geniculate bodies and
new fibres of the optic radiations
originate from them
OPTIC NERVES
OPTIC CHIASMA
OPTIC TRACTS
LAT. GENICULATE BODIES
OPTIC RADIATIONS
VISUAL PATHWAY
CONSISTS OF:
These extend from the LGB
to the visual cortex and
consist of the axons of third-
order neurons of visual
pathway
OPTIC NERVES
OPTIC CHIASMA
OPTIC TRACTS
LAT. GENICULATE BODIES
OPTIC RADIATIONS
OCCIPITAL CORTEX
VISUAL PATHWAY
CONSISTS OF:
Situated above and below
the calcarine fissures in the
occipital lobes extending up
to the occipital poles
OPTIC NERVES
OPTIC CHIASMA
OPTIC TRACTS
LAT. GENICULATE BODIES
OPTIC RADIATIONS
OCCIPITAL CORTEX
VISUAL PATHWAY
CONSISTS OF:
BLOOD SUPPLY
OF THE
VISUAL
PATHWAY
LESIONS OF VISUAL PATHWAYS
LESIONS OF VISUAL PATHWAYS
LESIONS OF VISUAL PATHWAYS
LESIONS OF VISUAL PATHWAYS
LESIONS OF VISUAL PATHWAYS
LESIONS OF VISUAL PATHWAYS
LESIONS OF VISUAL PATHWAYS
LESIONS OF VISUAL PATHWAYS
AND
THEIR ABNORMALITIES
1)LIGHT REFLEX
2)NEAR REFLEX
3)PSYCHOSENSORY REFLEX
1) LIGHT REFLEX
• When light is shone to one eye, both the pupils
constrict
• Constriction of the pupil to which light is shone is
called direct light reflex
• Constriction of that other pupil is called direct light
reflex consensual (indirect) light reflex
• Initiated by rods and cones
LIGHT REFLEX (PATHWAY)
2) NEAR REFLEX
• Occurs on looking at a near object
• Consists of TWO components:
– CONVERGENCE REFLEX
(CONTRACTION OF PUPIL ON CONVERGENCE)
– ACCOMMODATION REFLEX
(CONTRACTION OF PUPIL ON ASSOCIATED WITH ACCOMMODATION)
3) PSYCHOSENSORY REFLEX
• Refers to dilatation of the pupil in response
to sensory and psychic stimuli
• Very complex
• Mechanism is not elucidated
ABNORMALITIES
1)AMAUROTIC LIGHT REFLEX
2)MARCUS GUNN PUPIL
3)WERNICKE’S HEMIANOPIC PUPIL
4)ARGYLL ROBERTSON’S PUPIL
5)EFFERENT PATHWAY DEFECT
6)ADIE’S TONIC PUPIL
1) AMAUROTIC LIGHT REFLEX
• Lesions of the optic nerve or retina on the
affected side  complete blindness
• Absence of direct light reflex on the affected
side AND absence of indirect light reflex on
the normal side
2) MARCUS GUNN PUPIL
• Presence of a relative afferent pathway
defect (RAPD) due to
– incomplete optic nerve lesions
– severe retinal disease
• Paradoxical response of a pupil to light
3) WERNICKE’S HEMIANOPIC
PUPIL
• Lesion of the optic tract
• Light reflex is absent when light is thrown on
the temporal half of the retina of the affected
side and nasal half of the opposite side ;
while it is present when the light is thrown
on the nasal half of affected side and
temporal half of the opposite side
4) ARGYLL ROBERTSON PUPIL
(ARP)
• Lesions in the
region of tectum
• Both pupils are
slightly small in size
• Reaction to near
reflex is present,
but light reflex is
absent
5) EFFERENT PATHWAY REFLEX
• Efferent pathway defect (sphincter paralysis)
– Parasympatholytic drug (eg: atropine)
– Internal opthalmoplegia
– Third nerve paralysis
• Absence of both direct & indirect light reflex
and also near reflex on the affected side
• Presence of all reflexes on normal side
6) ADIE’S TONIC PUPIL
• Due to postganglionic parasympathetic
pupillomotor damage
• Reaction to light is absent, near reflex is very
slow and tonic on the affected side
• The affected pupil is larger (anisocoria)
Difference between the size of two pupils
[Normal size of pupil: 3-4mm]
Is not caused by optic nerve lesions or
other afferent pupil pathway defects.
It is a sign of autonomic dysfunction
CAUSES:
• Physiological anisocoria
– usually minimal, both pupils react well to light;
no dilatation lag
• Pathological anisocoria
– Usually a difference of 2mm or more
– May be either due to abnormal miosis or
mydriasis of one pupil
EVALUATION OF ANISOCORIA:
1. Pupil size in dim and bright illumination should
be noted first
2. Pupillary light reflex should be noted
3. Pharmacological test
– Suspected parasympathetic palsy (Pilocarpine)
– Suspected sympathetic palsy (Cocaine or
Hydroxyamphetamine)
REFERENCES
• Comprehensive Ophthalmology, 6th Edition, A K
Khurana, JAYPEE
• http://www.derangedphysiology.com/main/requi
red-reading/neurology-and-
neurosurgery/Chapter%204.6.2.3/visual-fields-
and-lesions-visual-pathways-cn-ii
• https://www.youtube.com/watch?v=cjnStgx-tb4

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NEURO-OPHTHALMOLOGY

  • 1. NEUR OPHTHALM O LOGY Prepared by Nur Hanisah Binti Zainoren
  • 2. OBJECTIVES Anatomy of the visual pathway Lesions of the visual pathway Pupillary reflexes and their abnormalities Anisocoria
  • 3.
  • 5. OPTIC NERVES VISUAL PATHWAY CONSISTS OF: The fibres of optic nerve originate in the retina - divided into the temporal & nasal halves of the fovea centralis. Join the optic chiasma at the anterolateral angle
  • 6. OPTIC NERVES OPTIC CHIASMA VISUAL PATHWAY CONSISTS OF: A flat band-like structure lying above the pituitary fossa In the optic chiasma, there is semi- decussation of the nerve fibres • Nerve fibres from the nasal side of each retina CROSS-OVER to the opposite side • Nerve fibres from the temporal side of DO NOT CROSS but pass into optic tracts of the same side
  • 7. OPTIC NERVES OPTIC CHIASMA OPTIC TRACTS VISUAL PATHWAY CONSISTS OF: Originate from the postero-lateral angle of the optic chiasma Cylindrical bands running outwards & backwards to end in the lateral geniculate bodies They consist of the temporal fibres of the same side and the nasal fibres of the opposite side
  • 8. OPTIC NERVES OPTIC CHIASMA OPTIC TRACTS LAT. GENICULATE BODIES VISUAL PATHWAY CONSISTS OF: Oval structures situated at the posterior end of the optic tracts The fibres of the optic tracts end in the lateral geniculate bodies and new fibres of the optic radiations originate from them
  • 9. OPTIC NERVES OPTIC CHIASMA OPTIC TRACTS LAT. GENICULATE BODIES OPTIC RADIATIONS VISUAL PATHWAY CONSISTS OF: These extend from the LGB to the visual cortex and consist of the axons of third- order neurons of visual pathway
  • 10. OPTIC NERVES OPTIC CHIASMA OPTIC TRACTS LAT. GENICULATE BODIES OPTIC RADIATIONS OCCIPITAL CORTEX VISUAL PATHWAY CONSISTS OF: Situated above and below the calcarine fissures in the occipital lobes extending up to the occipital poles
  • 11. OPTIC NERVES OPTIC CHIASMA OPTIC TRACTS LAT. GENICULATE BODIES OPTIC RADIATIONS OCCIPITAL CORTEX VISUAL PATHWAY CONSISTS OF:
  • 12.
  • 14. LESIONS OF VISUAL PATHWAYS
  • 15. LESIONS OF VISUAL PATHWAYS
  • 16. LESIONS OF VISUAL PATHWAYS
  • 17. LESIONS OF VISUAL PATHWAYS
  • 18. LESIONS OF VISUAL PATHWAYS
  • 19. LESIONS OF VISUAL PATHWAYS
  • 20. LESIONS OF VISUAL PATHWAYS
  • 21. LESIONS OF VISUAL PATHWAYS
  • 24.
  • 25. 1) LIGHT REFLEX • When light is shone to one eye, both the pupils constrict • Constriction of the pupil to which light is shone is called direct light reflex • Constriction of that other pupil is called direct light reflex consensual (indirect) light reflex • Initiated by rods and cones
  • 27.
  • 28.
  • 29. 2) NEAR REFLEX • Occurs on looking at a near object • Consists of TWO components: – CONVERGENCE REFLEX (CONTRACTION OF PUPIL ON CONVERGENCE) – ACCOMMODATION REFLEX (CONTRACTION OF PUPIL ON ASSOCIATED WITH ACCOMMODATION)
  • 30. 3) PSYCHOSENSORY REFLEX • Refers to dilatation of the pupil in response to sensory and psychic stimuli • Very complex • Mechanism is not elucidated
  • 31. ABNORMALITIES 1)AMAUROTIC LIGHT REFLEX 2)MARCUS GUNN PUPIL 3)WERNICKE’S HEMIANOPIC PUPIL 4)ARGYLL ROBERTSON’S PUPIL 5)EFFERENT PATHWAY DEFECT 6)ADIE’S TONIC PUPIL
  • 32. 1) AMAUROTIC LIGHT REFLEX • Lesions of the optic nerve or retina on the affected side  complete blindness • Absence of direct light reflex on the affected side AND absence of indirect light reflex on the normal side
  • 33. 2) MARCUS GUNN PUPIL • Presence of a relative afferent pathway defect (RAPD) due to – incomplete optic nerve lesions – severe retinal disease • Paradoxical response of a pupil to light
  • 34. 3) WERNICKE’S HEMIANOPIC PUPIL • Lesion of the optic tract • Light reflex is absent when light is thrown on the temporal half of the retina of the affected side and nasal half of the opposite side ; while it is present when the light is thrown on the nasal half of affected side and temporal half of the opposite side
  • 35. 4) ARGYLL ROBERTSON PUPIL (ARP) • Lesions in the region of tectum • Both pupils are slightly small in size • Reaction to near reflex is present, but light reflex is absent
  • 36. 5) EFFERENT PATHWAY REFLEX • Efferent pathway defect (sphincter paralysis) – Parasympatholytic drug (eg: atropine) – Internal opthalmoplegia – Third nerve paralysis • Absence of both direct & indirect light reflex and also near reflex on the affected side • Presence of all reflexes on normal side
  • 37. 6) ADIE’S TONIC PUPIL • Due to postganglionic parasympathetic pupillomotor damage • Reaction to light is absent, near reflex is very slow and tonic on the affected side • The affected pupil is larger (anisocoria)
  • 38. Difference between the size of two pupils [Normal size of pupil: 3-4mm]
  • 39. Is not caused by optic nerve lesions or other afferent pupil pathway defects. It is a sign of autonomic dysfunction CAUSES: • Physiological anisocoria – usually minimal, both pupils react well to light; no dilatation lag • Pathological anisocoria – Usually a difference of 2mm or more – May be either due to abnormal miosis or mydriasis of one pupil
  • 40. EVALUATION OF ANISOCORIA: 1. Pupil size in dim and bright illumination should be noted first 2. Pupillary light reflex should be noted 3. Pharmacological test – Suspected parasympathetic palsy (Pilocarpine) – Suspected sympathetic palsy (Cocaine or Hydroxyamphetamine)
  • 41. REFERENCES • Comprehensive Ophthalmology, 6th Edition, A K Khurana, JAYPEE • http://www.derangedphysiology.com/main/requi red-reading/neurology-and- neurosurgery/Chapter%204.6.2.3/visual-fields- and-lesions-visual-pathways-cn-ii • https://www.youtube.com/watch?v=cjnStgx-tb4