• A 53 year old patient with acute diplopia.
• Previous episodes few years ago , which
lasted two months and recovered.
• Diabetes, and hyprlipedemia.
• Visual acuity : 20/20 OU.
• Pupils : Equally reactive , pupils equal in size.
• Diabetes, hypertension, hyperlipedemia, smoking, high
• Pupils is spared.
• Pupil involvement reported only in 14%-32% , but
anisocoria (difference in pupil size) is less than 1 mm
• Improve within 4-12 weeks (defer neuro-imaging).
• 78 year old man with acute diplopia, and
• Diabetes, hypertension, atrial tachycardia.
• Prior history of tight feeling around the eye
with 20 seconds of diplopia.
• No history of jaw claudication or transient
• Pupil involvement indicates compression of
the pupillary fibers.
• Posterior communicating artery
aneurysm, or mass.
• Appropriate neuro-imaging is (MRI/MRA,
MRI/CTA,Angiogram is the gold standard
for aneurysm detection).
Risk of Aneurysm and
“Rule of Pupil”
Ophthalmoplegia Pupil Aneurysm Risk
Complete/Partial Complete 86%-100%
Partial Spared 30%
Complete Spared very low
If signs of sub-arachnoid hemorrhage present (headache, photophobia, nausea) “rule
• A 67 year old man presents with pain in his right eye
for 5 days.
• Hypertension and ischemic heart disease on treatment.
• No double vision.
• VA : 20/30 OU.
• Mild nuclear sclerosis cataracts.
• Fundus: normal.
• Painful Horner’s syndrome is a neurologic
• Although can be seen in many types of
headaches (Cluster, Migraine etc).
• Rule out ICA dissection.
• MRI/MRA of the head/neck/upper
mediastinum is indicated.
• A 68 year old patient with sudden loss of vision in
the right eye.
• History of episodes transient loss of vision.
• Diabetes for 30 years.
• Feeling unwell lately with, and loss of appetite,
malaise and myalgias.
• Visual acuity: Count finger right , 20/30 left.
• Right RAPD.
• New onset of headache (temporal) , acute or
transient loss of vision, jaw claudication, weight loss,
fever, and myalgias.
• Age usually over 60.
• Occult GCA ( No systemic symptoms, transient diplopia
or transient visual loss).
• A true neuro-ophthalmic emergency (54-95% second eye
involvement if untreated) !
• Giant cell arteritis (systemic vasculitis, Aortitis in
20% consider PET/MRA).
Central retinal artery
occlusion Branch-retinal artery occlusion
• Both the retina and optic nerve look normal.
• PION is relatively common in Giant Cell arteritis.
• Flourescin angiogram can show choroidal
• Involvement of 2 circulations (systemic vasculitis),
retinal artery occlusion and AION indicate giant
• Stat ESR , CRP and CBC (platelets).
• ESR can be normal in 15-20% of cases.
• CRP is more sensitive and specific.
• CRP and CBC have 97% sensitivity and specificity.
• Start high dose systemic steroids (IV or Oral)
immediately upon suspicioun ( AAION can develop in
fellow eye within days if untreated !)
• Arrange for temporal artery biopsy within 2 weeks ,
while patient is on steroids.
QuickTime™ and a
are needed to see this picture.
• Systemic steroids for a at least 1-2 years.
• Titrate dose according to laboratory
indices (CRP,ESR) and symptoms.
• Manage diabetes and osetoporosis.
• Collaboration with rheumatologist.
• 52-year-old, morbidly obese man presents with
severe headache (worst in his life).
• Ischemic cardiac disease and angioplasty, COPD,
hypertension, and NIDDM.
• On examination: complete right ptosiswith
unreactive mid-dilated right pupil، left partial
ophthalmoplegia with V1 hypesthesia.
• “Worst headache in my life”.
• Visual loss, and/or ophthalmoplegia ( uni- or bilateral).
• Patients usually present 2 weeks after ictus.
• > 80% did not have history of pituitary tumor
• Ophthalmoplegia (extension to cavernous sinus with
cranial nerve involvement).
• Life threatening (hypotension, shock) because of
hypo-pituitarism, and low cortisol levels, and diabetes
• A 50 year old with blurred vision and
headache for the last 2 weeks.
• Medical History : Diabetes for 5 years.
• Smoker 15 years.
• No prior Surgeries
• Conscious and oriented.
• Visual acuity : 20/20 OU
• Pupils : PERL no RAPD.
• Normal anterior Segment .
• Normal ocular motility.
• CT and MRI/MRV - normal.
• Blood pressure 220/150 !
• Accelerated hypertension with target organ
• Papilledema must be present for diagnosis !
• Dysfunction of cerebral blood flow
autoregultaion causing cerebral edema.
• Pre-eclampsia .
• Encephalopathy can be present.
• 60 year old man with myelodysplastic
disorder on chemotherapy.
• Proptosis, fever, and dyspnea .
• Periorbital swelling and erythema, which
got worse over 3 days.
• Visual acuity : 20/20 Both eyes.
• Normal pupils, ocular motility and fundus
• Vascular thrombosis, tissue necrosis, and fungal
• The mortality rate is as high as 90%.
• Diabetic ketoacidosis , immunosuppressed, organ
transplant patients, steroid use, and
• Other fungal organisms: Aspergillus.
• Pain and ophthalmoplegia.
• CT of the orbit/paranasal sinuses/cavernous sinus
or MRI of the orbit with fat suppression.
• Immediate biopsy (ENT/Orbit) , with debridement.
• Orbital exenteration is not always needed.
• Correct any metabolic acidosis to reduce unbound
iron (critical for the proliferation of mucor)
• Local delivery of amphotericin B with indwelling
• Systemic antifungal (IV liposomal encapsulated
Amph B less nephrotoxic +- posaconazole).
• Boost immunity (correct neutropenia).
• Medical therapy and surgical debridement increase
the survival rate (78%) compared to medical
management alone (57.5%).
Non-septate hyphae with branching
at 90 degrees.
• Pupil involvement in 3rd nerve palsy suggests compressive lesion
(aneuurysm), get and MRI/MRA or MRI/CTA.
• Always rule out ICA dissection in acute Horner’s syndrome.
• Always rule out GCA as the etiology for ophthalmoplegia or
visual loss in >60 year patients.
• In acute severe headache with ophthalmoplegia with multiple CN
involvement think of pituitary apoplexy.
• Proptosis and eye redness in diabetic/immunospressed patients
can be due to life-threatening fungal infection.