This document discusses approaches to vision loss. It defines various patterns of vision loss including transient monocular, persistent monocular, and binocular vision loss. It describes causes of transient monocular vision loss such as amaurosis fugax which can be due to circulatory, ocular, or neurologic factors. Key factors in evaluating vision loss include whether it is monocular or binocular, the pattern and degree of loss, tempo of onset, and associated symptoms. Common causes of sudden monocular vision loss discussed include central retinal artery occlusion and optic neuritis.
visual field- its assessment, defects, diseases associated. Types of visual field defects. visual field defects in glaucoma in detail. Humphrey's visual field analyser chart.
visual field- its assessment, defects, diseases associated. Types of visual field defects. visual field defects in glaucoma in detail. Humphrey's visual field analyser chart.
The presentation includes physiological mechanism of different functional classes of eye movements such as horizontal & vertical eye movements, saccades, persuits, vestibuloocular reflex, Bell's phenomenon and it also includes different disorders that causes abnormal supranuclear eye movements e.g. skew deviation, Perinaud syndrome, INO.
Transient loss of vision is common clinical problem that ophthalmologists and neurologists can face. This presentation will highlight clinical approach and important causes with management.
The presentation includes physiological mechanism of different functional classes of eye movements such as horizontal & vertical eye movements, saccades, persuits, vestibuloocular reflex, Bell's phenomenon and it also includes different disorders that causes abnormal supranuclear eye movements e.g. skew deviation, Perinaud syndrome, INO.
Transient loss of vision is common clinical problem that ophthalmologists and neurologists can face. This presentation will highlight clinical approach and important causes with management.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
2. Headings
• Definition and aspects
• Approach to vision loss
• Patterns of vision loss
• Transient Monocular Vision Loss
• Persistent Monocular vision Loss
• Binocular vision loss
• Cerebral vision loss
• Functional vision loss
3. Aspects of Vision Loss
* Visual standards, Resolution of the International Council of Ophthalmology (2002)
4. Grades of Visual Impairment
* Visual standards, Resolution of the International Council of Ophthalmology (2002)
5. Causes of Vision Loss
Cause World South-Asia
Refractive error 20.62 (18.62 - 22.55) 36.76 (34.29 - 39.05)
Cataract 34.47 (25.69 - 43.35) 35.15 (27.18 - 43.16)
Age-related macular Degeneration 8.30 (2.85 - 15.42) 5.66 (2.05 - 10.35)
Glaucoma 5.64 (1.33 - 11.72) 2.40 (0.65 - 4.83)
Corneal opacity 3.46 (0.53 - 7.77) 2.64 (0.47 - 5.82)
Diabetic retinopathy 1.07 (0.15 - 2.44) 0.18 (0.03 - 0.38)
Trachoma 0.98 (0.80 - 1.16) 0.04 (0.01 - 0.07)
Other causes/unidentified 25.46 (9.82 - 44.20) 16.72 (5.97 - 30.58)
Percentage of blindness by cause for all ages in 2015
Flaxman, SR, Bourne, RRA, Resnikoff, S et al. Global causes of blindness and distance vision impairment
1990–2020: a systematic review and meta-analysis. Lancet Glob Health. 2017
7. Approach to vision loss
• Age :
Degenerative and vascular disorders seen in adults
Neoplasms/ tumor types are age dependent
• Sex:
Optic neuritis and giant cell arteritis are more prevalent
in females
8. Approach to vision loss
• Is the visual loss monocular/ binocular ?
Monocular vision loss : abnormality in the eye itself or in
the optic nerve anterior to the chiasm
Binocular vision loss result from bilateral anterior lesions
or more likely chiasmal / retrochiasmal lesion
• Is the visual loss transient/ persistent ?
Neuro-Ophthalmology : Diagnosis and Management Grant T. Liu, Nicholas J. Volpe
9. Approach to vision loss
• What is the pattern and degree of vision loss ?
• What is the tempo of onset ?
• Is the visual loss static /progressive/ fluctuating/resolving?
• What are the associated symptoms/signs or if any triggers ?
10. Painful Vision Loss
Causes Characteristics and Associations
Vascular visual loss
ICA dissection( CRAO /AION)
Carotid occlusion
Neck Pain, Horner Syndrome
Ocular ischemic syndrome Orbital pain , Iris neovascularization
Iridocyclitis, retinal hemorrhages
Giant cell arteritis Jaw claudication, Systemic symptoms
Optic neuritis Periorbital/Pain on eye-movement
Angle-closure glaucoma Nausea,vomiting,conjunctival injection
Orbital apex syndrome Periorbital pain
Other cranial nerve involvement
Ocular trauma H/O Trauma
Pituitary Apoplexy Sudden temporal headache/Periorbital pain
,rapidly worsening visual loss
11. Visual field Interpretation- Pattern of vision loss
1. Monocular vs Binocular
2. Central vs Peripheral
3. Hemianopic or not
4. Congruous vs Incongruous Homonymous hemianopia
25. Amaurosis Fugax
• Acute onset, brief partial or complete monocular vision
loss
• Brief, usually <15 minutes and rarely > 30 minutes, most
patients are affected for only 1–5 min
• Usually begins in the upper field :Altitudinal vision loss
with a shade /curtain effect seen in 15- 20%
Mungas JE, Baker WH. Amaurosis fugax. Stroke 1977
26. Amaurosis Fugax
Donders RC, Dutch TMB Study Group Clinical features of transient monocular blindness. J Neurol
Neurosurg Psychiatry. 2001
Clinical Feature Implication
Age > 45 years: Ischemic cause likely
< 40 years: Benign migrainous cause likely
Frequency of events • Isolated events may be d/t embolism
• Repeated events d/t hypoperfusion in arterial stenosis
Onset • Over seconds: more likely Embolic/ vasospastic
• Over minutes: Hypoperfusion events
Duration • Lasting seconds : ocular , orthostatic hypotension
• 2- 30 minutes: Ischemic event
• Minutes to hours: Vasospastic /Migrainous event
29. Hayreh S.S., Zimmerman M.B. Amaurosis fugax in ocular vascular occlusive disorders:
prevalence and pathogeneses. Retina. 2014
30. Amaurosis Fugax
• Comprises approximately 20-25% of TIAs
• Annual incidence of stroke was 2% / four times greater than a normal
population
• TMVL secondary to carotid artery stenosis, the 3-year ipsilateral
stroke rate (10%) was half that for hemisphere TIAs (20%) -NASCET
• The risk of death in patients with TMVL and atheromatous carotid
stenosis is around 4%/yr, mainly related to myocardial infarction
KIine LB. The natural history of patients with amaurosis fugax. Ophthalmol Clin North Am 1996
PooleCJM, RossRussell RW: Mortality and stroke after amaurosis fugax./ Neurol Neurosurg Psychiatry1985
32. 3-year absolute reduction of risk of stroke with carotid
endarterectomy in presence of 3 risk factors was 14.3%
Benavente O et al. Prognosis after transient monocular blindness associated with carotid-
artery stenosis. N Engl J med. 2001
34. Transient Binocular Vision Loss
Clinical Feature Migraine Occipital Seizure Vertebrobasilar TIA
Duration 20-30 minutes Variable Seconds to minutes
Headache Frequent headaches
Occur after vision loss
During or after vision
loss
During or after
vision loss
Typical visual
symptom
Hemifield marching Hemifield stationary Hemifield or total
Positive phenomena
•Fortification scotoma
•Formed images
Common
Uncommon
Rare
Common
Rare
Uncommon
Associated features Nausea, Photophobia
Paresthesias,Dysphasia
Eye deviation,
automatisms, loss of
consciousness
S/S Brainstem dysfn.
Dizziness, ataxia,
diplopia, numbness,
dysarthria
35. Sudden monocular vision loss: Clinical scenario
• 42 year old male presented with sudden onset of painless
blurring of vision in right eye since past 7 days
• He also complains of distortion of images and micropsia.
• On examination, visual acuity is 6/24 in right eye, with a
RAPD and central scotoma on visual field testing
38. Whether the visual loss a result of a lesion of the
Optic nerve or a lesion of the macula ?
SIMILARITIES
1. Decreased visual acuity
2. Central scotomas on visual fields
3. RAPD can occur in both*
4. Color vision can be affected in both*
39. Differences: ON vs Macula
Symptom Optic nerve abnormality Macular abnormality
Metamorphopsia Rare Common
Pain Usually present in optic neuritis Absent
Color vision/dyschromatopsia More affected
(for the degree of VA Deficit)
Less affected
Photopsia Rare Common
Darkening of vision Common Rare
Recognition of peripheral
field loss
Common Rare
Glare/ Light sensitivity Rare Sometimes
TVO Occasionally Rare
40. Differences
Sign/Investigations Optic nerve abnormality Macular abnormality
RAPD Common Rare
Ophthalmoscopy Swollen pale or normal optic
nerve
Macular abnormality
Pale optic nerve +/-
Visual field defects Central, Cecocentral, nasal,
arcuate, altitudinal
Positive Central
scotoma
Recovery following bright
light exposure
Normal Abnormal
ERG/OCT Normal
Nerve fibre layer thinning +/-
Abnormal
VEP Large latency delay Small latency delay
42. RAPD
• Result of consensual and bilateral nature of the light reflex
• Unilateral or asymmetrical bilateral disruption of the afferent
limb of light reflex
• Detected by swinging flash light test
• Can quantitate the severity of retinal ganglion cell and optic
nerve damage
44. • The relative afferent pupillary defect (RAPD) was measured in ten
patients, each of whom had a dense cataract in one eye only.
• All patients with mature or nuclear cataracts had a measureable
RAPD in the other eye
• May be due to increased intraocular scatter of light by the cataract
• RAPD in the same eye as a unilateral cataract, likely to be a major
defect of the anterior visual pathway in that eye.
45. • The ‘better’ eyes had optic nerve or retinal dysfunction.
• The eyes with worse visual acuity but no afferent pupillary
defect had an abnormality of the ocular media.
47. Sudden Monocular Vision Loss with Progression
Optic neuritis
Leber’s hereditary optic neuropathy
Anterior ischemic optic neuropathy ( arteritic/nonarteritic)
48.
49. CRAO
• Painless sudden monocular vision loss; usually embolic
etiology (commonly Carotid artery atherosclerotic disease )
• Prudent to rule out giant cell arteritis ( if also age>50 yrs)
• Vascular emergency ; evaluate on lines of cerebral infarction
• Fundus may be normal in acute stages; repeat examination
necessary
53. • Annual risk of stroke in patients with visible asymptomatic retinal
cholesterol emboli :
8.5% vs 0.8% controls ( RR 9.9; 95% CI (2.3 to 43.1); P = 0.002)
• Stroke occurred in 15.0% RAO group vs 8.0% controls (P < 0.001).
RAO was associated with an increased risk of stroke occurrence
(hazard ratio, 1.78; 95% confidence interval, 1.32–2.41)
Risk of stroke
Bruno A, Vascular outcome in men with asymptomatic retinal cholesterol emboli. A cohort
study. Ann Intern Med. 1995
Rim TH, et al. Retinal Artery Occlusion and the Risk of Stroke Development: Twelve-Year
Nationwide Cohort Study. Stroke. 2016
54. • Prognosis of CRAO is considered dismal, with some studies reporting as
few as 8% experiencing a recovery in visual acuity
• All patients with CRAO should be admitted for immediate workup and
initiation of secondary prevention. MR brain may detect concomitant
cerebral ischemia in 25% pts. Of CRAO
• Intraarterial thrombolysis or intravenous thrombolysis are of limited
benefit . ???
• In one metanalysis, systemic fibrinolysis (<4.5 hours onset) resulted in rate
of recovery is nearly 3 times that in the natural history cohort (P < .001),
with a 32.3% absolute RR and a NNT of 4.0
Management
Lee J, et al. Co-occurrence of acute retinal artery occlusion and acute ischemic stroke: diffusion-
weighted magnetic resonance imaging study. AM J Ophthalmol. 2014
Ahn SJ, : Efficacy and safety of intra-arterial thrombolysis in central retinal artery occlusion. Invest
Ophthalmol Vis Sci 2013
55. Classic features of a unilateral optic neuropathy
1. Central visual loss
2. Clear view through the ocular media to the optic nerve
3. Relative afferent pupillary defect
4. Swollen or pale optic nerve head
Exceptions –
N-AION: Visual Acuity good despite altitudinal vision loss
Retrobulbar optic neuritis : Disc is normal for 4-6 weeks
56. Ischemic optic neuropathies
• Most common optic neuropathies in patients >50 yrs age
• Involvement of posterior ciliary arteries: atherosclerosis or vasculitis
• AION (90% of total cases) more common than PION
• Nonarteritic ischemic optic neuropathy is more common than
arteritic ION
Repka MX. Clinical profile and long-term implications of anterior ischemic optic neuropathy.
Am J Ophthalmol. 1983
57. Ischemic optic neuropathies
Parameter Arteritic AION NAION
Age (years) >65 45- 70
Sex F:M ( 3:1) M=F
Systemic symptoms
+ Headache/pain
>50% : Polymyalgia rheumatica
25% : Isolated visual s/s
Absent
Amaurosis Fugax Common ( 32%) Uncommon (2.5%)
ESR and CRP Raised
(ESR normal in 12%)
Normal
HayrehSS. Anterior ischaemic optic neuropathy: differentiation of arteritic from non-arteritic type
and its management.Eye.1990
58. Ischemic optic neuropathies
Parameter Arteritic AION NAION
Degree of vision loss Severe
70% < 6/60
Less severe
50% Better than 6/18
Arteriosclerotic Risk
Factors
According to Age Present
Binocular
involvement
30-50%
Interval often <1 week
20-30%
Interval rarely < 6 months
Improvement Rare
25% HM+ / worse
30% improvement
Ophthalmoscopy Pallid edema , Cotton wool spots
Disc hemorrhages
Disc edema, hemorrhages
Disk at risk
FFA Segmental Choroidal
hypoperfusion
Normal,
Delayed disc filling
60. 37-year-old woman
• Four weeks prior to presentation, she noticed painless decreased vision in
the inferior visual field in the right eye, which worsened over 4 to 5 days.
• She had a brain MRI that showed no optic nerve enhancement, but
showed one small nonenhancing periventricular T2 high signal lesion.
• She did not receive treatment. Her vision failed to improve during the
following 4 weeks.
• On neuro-ophthalmic examination, visual acuity was 6/6 left and 6/24 in
right eye and mild red desaturation was present in the right eye. RAPD +
Case vignette
63. NAION Vs Optic neuritis
Parameter NAION Optic neuritis
Age (years) , Sex >50, M=F <40, F>M
Pain Absent 90% of presentations
Onset Acute / One time event
Few cases have progression
Progressive
Recovery Static ( >2/3rd no improvement) Good recovery
Optic disc Pale disc, Disc at risk
Peripapillary hemorhages +
33% disc edema
Visual fields Altitudinal/nerve fibre bundle
defect
Central
FFA Delayed disc filling Normal
MR Brain No Optic nerve enhancement Enhancement + 84%
Rizzo JF, Lessell S. Optic Neuritis and Ischemic Optic Neuropathy Overlapping Clinical Profiles.
Arch Ophthalmol. 1991
64. • Altitudinal disc swelling and Hemorrhage on the swollen disc
was more common in AION than in ON
• AION was the clinical diagnosis
82% of the cases with altitudinal edema,
81% of the cases with disc hemorrhages
93% of the cases with pallid edema
90% of the cases with arterial attenuation
65. • Glaucoma, CRAO and ION were correctly identified by atleast
1/5 observers with accuracy >80%
Helpful features in differentiating entities:
1. Retinal arteriolar attenuation and sheathing in CRAO , AION
2. Segmental temporal pallor in hereditary (bilateral) and ON
(unilateral)
3. Pathological disc cupping for glaucoma
66. Optic Neuritis
Classical Features
Female , Age 77% , 32 +/- 6.7 years
Onset to peak Hours to days ( upto 2 weeks)
Ocular Pain 92% precedes vision loss , Usually lasts 3- 5 days
Swollen optic disc 35%
Visual Acuity 55% (6/7.5 to 6/60)
Recovery Untreated: Vision stops getting worse at 7 days, starts improving in
80% within 3 weeks; most recovery in 4 wks ; 70% recover 6/6
Treated: No difference ,except recovery faster within first 2 weeks
Recurrence Cumulative probability over 5 years:
19% : affected eye, 17% :unaffected eye, and 30% for either eye
Conversion to MS
(15 year)
No brain lesion: 25%, One or more lesions: 72%
Beck RW, Cleary PA, Anderson MM Jr, et al. A randomized, controlled trial of corticosteroids in the
treatment of acute optic neuritis. The Optic Neuritis Study Group. N Engl J Med 1992
67. Typical Vs Atypical ON
Optic Neuritis Atypical ON/ Red flags
Young Adults (Mean age 32 years)
Predominantly Females (77%)
Age > 45 years
Subacute visual loss over hours to days Progression of visual loss after 2 weeks
Presence of Pain (90%) Absence of Pain/ persistent pain
Predominantly Unilateral involvement Bilateral involvement
Optic disc edema (35%) Severe disc edema ,Vitreous cells and
hemorrhage, Macular star
Optic atrophy at presentation
Photopsia /phosphenes (1/3) Positive phenomena : Retinal mimic
Good recovery
Monophasic course
• Lack of partial recovery within 4 weeks
of onset of vision loss
• Relapse after stopping steroids
70. Case scenario
• 26 year female presented with C/C of right upper limb
radicular pain and neck pain 1.5 months PTA
• Right eye vision loss , inferior altitudinal at onset, 4 weeks
prior to presentation with complete loss 14 days post onset
• Horizontal diplopia, more on focussing to right side
• Painful left eye vision loss 2 weeks PTA with complete loss
7 days after onset
• Headache , bifrontal and moderate grade since 2 weeks PTA
73. Optic disc edema vs. Papilledema
Clinical features Optic disc edema/Papillitis Papilledema
Laterality Unilateral > Bilateral Bilateral, may be asymmetric
Early central vision loss
(visual acuity impaired)
Common Uncommon
Color vision Abnormal Preserved until late
Typical visual field defect Central or paracentral scotoma,
arcuate or altitudinal defect
Enlarged physiologic blind spot,
arcuate defect, nasal step,
inferotemporal loss,
concentric constriction
Friedman, D.I. Papilledema and idiopathic intracranial hypertension. Continuum (Minneap Minn). 2014
74. Optic disc edema vs. Papilledema
Clinical features Optic disc edema Papilledema
Spontaneous venous
pulsations
May be present Absent
Afferent pupillary defect Present if unilateral or asymmetric
vision loss
Usually absent unless
asymmetric visual loss
Disc leakage on
fluorescein angiogram
May be present Yes
Associated symptoms Pain on eye movement, other
symptoms specific to etiology
Headache, diplopia,
photophobia, nausea,
vomiting, meningismus
76. Papilledema
• Optic disc swelling secondary to raised ICP
• Secondary to blockage of axoplasmic flow in nerve fibres
• An intracranial mass lesion and malignant hypertension
should be excluded
• CSF opening pressure:
Abnormal values are >28 cm H20 in children and >25 cm H20
in adults (Normal of 6cm to 25cm H20 – 95%CI)
1. Avery RA, Shah SS, Licht DJ, et al. Reference range for cerebrospinal fluid opening pressure in
children. N Engl J Med 2010.
2. Lee SC, Lueck CJ. Cerebrospinal fluid pressure in adults. J Neuroophthalmol 2014
77. Spontaneous venous pulsations
• Present in 90% of normal subjects
• SVPs occurred only in patients with CSF pressures below 19 cm H2O
and in the absence of optic disc edema
• In IIH ,CSF pressure often fluctuates and may even be normal at
times. SVPs may hence be present at times
Levin BE. The clinical significance of spontaneous pulsations of the retinal vein.
Arch Neurol 1978;35:37–40
78. Transient Visual Obscurations
• Brief episodes (lasting seconds) of monocular or binocular
black-outs/gray-outs of vision in patients with optic disc edema
• Precipitated by postural changes / valsalva maneuvres/eye
movement
• TVOs may be the only symptom of raised ICP, which is their
most likely cause
• Due to transient decreased perfusion of the optic nerve head
Biousse V, Trobe JD. Transient monocular visual loss. Am J Ophthalmol 2005
79. Etiology of Papilledema
Common Causes Uncommon
IIH (44%) Dural sinus AV Malformation
Intracranial mass Lesion (21%) OSA
Hydrocephalus (17%) GBS
Venous sinus thrombosis (9%) CIDP
Intracranial Hemorrhage Spinal cord tumors
Meningitis Craniosynostosis
Neuro-Ophthalmology at a Tertiary Eye Care Centre in India. Sharma,Pradeep MD; Saxena, Rohit
MD, Journal of Neuro-Ophthalmology 2017
80. IIH: Clinical features
Features IIHT
(n=165)
AIIMS
(n= 89)
Mean Age 29(7.4) years 29.9(11)
Females 97.6% 82%
BMI 39.9(8.3) (88%obese) 27.1 ± 5.4 (67% obese)
Headache
TVO
Tinnitus
Diminution of vision
Binocular diplopia
84%
68%
52%
32%
18%
92%
53%
13%
62%
24%
Recent gain in weight 45% 11%
CSF Opening pressure;cm 34.3(8.6) 27.2(7.3)
M. Wall, The idiopathic intracranial hypertension treatment trial: clinical profile at baseline, JAMA Neurol. 71 (2014)
Agarwal A, Vibha D, Prasad K, Bhatia R, Singh MB, Garg A, et al. Predictors of poor visual outcome in patients with idiopathic
intracranial hypertension Clin Neurol Neurosurg. 2017
81.
82. Papilledema vs. Pseudopapilledema
Features Papilledema Pseudo-Papilledema
Disc colour Hyperemic Pink , yellowish pink
Disc Margins Indistinct early at superior and
inferior pole
Irregularly blurred, may be
lumpy
Vessels Normal distribution, Fullness
SVP Absent
Emanate from centre
Frequent anomalous pattern
SVP +/-
Nerve fiber layer Dull as a result of edema No edema
Hemorrhages Splinter Subretinal, retinal, vitreous
83.
84. Cerebral blindness
1. Complete loss of visual sensation, including light and
dark perception
2. Loss of reflex lid closure to bright illumination/
threatening gestures;
3. Retention of the pupillary light reaction and near
response;
4. Integrity of normal retinal structures;
5. Normal extraocular movements
Fraser JA, Newman NJ, Biousse V. Disorders of the optic tract, radiation and occipital lobe. Handb Clin
Neurol 2011
86. Deficit Localization
Achromatopsia/Dyschromatopsia Bilateral Lesions of Lingual Gyri
Apperceptive visual form agnosia Lateral occipital cortex
Associative visual agnosia Left or b/L lesions of the parahippocampal,
fusiform, and lingual gyri
Prosopagnosia Right or b/l fusiform gyri
Pure alexia Left occipitotemporal lesions
Ventral stream: Visuo-perception
94. • Prospective cohort study done in Department of Neurology at King
George Medical University, Uttar Pradesh, Lucknow over a span of
2 years (October 2011-September 2013)
• 64 patients were included in the study: 27 cases were male and 37
cases were female
95. DIAGNOSIS Percentage of patients
Demyelinating/inflammatory/ischemic
Optic neuropathy
37.5%
Chronically raised ICP 37.5%
Compressive Optic neuropathy 9.4%
Cortical vision impairment 15.6%
Distribution of etiology
96. Neuro-Ophthalmology at a Tertiary Eye Care Centre in India.
Sharma,Pradeep MD; Saxena, Rohit MD, Journal of Neuro-Ophthalmology
• Retrospective study (Jan 2015 – December 2015) at RPC/AIIMS
• 1597 patients (5% of total) were referred for neuropthalmology
evaluation (out of which 1334 were deemed valid)
• Mean age of presentation was 30.8 ± 19.5 years (range:
3months–88 years)
• M:F : 2.02
• Sixteen percent (n = 263) of patients were incorrect referrals
including retinal dystrophy, maculopathy, cataract, and
refractive error
97. Neuro-Ophthalmology at a Tertiary Eye Care Centre in India
DIAGNOSIS Percentage of patients
Optic nerve disorders
Disc edema +
63.8% (1020)
33% (335)
Disc edema -- 67% (635)
Cranial nerve palsies 7%
Cortical visual impairment 6.5%
Others 6%
Incorrect referrals 16%
Sudden onset: vascular, inflammatory, infectious. Gradual: degenerative, compressive
Pattern: right/ left eye, field involved. Degree: complete, greyness, distortion
Progressive: compressive, Plateau/improve: vascular or inflammatory
Headache: migraine/ icp/compressive
10% for >50% stenosis in TMB vs 20% in hemispheric strokes
Pain: Giant cell arteritis/ Carotid dissection
Most common: Carotid artery atherosclerotic disease ; 50-70% of cases of CRAO
MRI and MRA 25% of patients with acute retinal ischemia (whether permanent or transient) will have concomitant acute
cerebral ischemia
CRAO: attenuated vessels, pale retina at posterior aspect, emboli esp. at bifurcation, and ofcourse cherry red spot
Pain: Giant cell arteritis/ Carotid dissection
Pain: Giant cell arteritis/ Carotid dissection
NAION: Painless acute, progress hours to days, RAPD+, altitudnal vision loss
Optic disc swelling, peripapillary hges, disk at risk, superior optic atrophy
NAION: Painless acute, progress hours to days, RAPD+, altitudnal vision loss
Optic disc swelling, peripapillary hges, disk at risk, superior optic atrophy