My Talk in AFHSR Targeted the non-ophthalmologists

1. Eslam Elkohly, FRCS (Glasgow)
Ophthalmology Senior Registrar

4. Neuro-Ophthalmology
 Sudden loss of vision
 Visual Field loss
 Diplopia
 Headache

5. Sudden loss of vision
 Case scenario: 73 YO patient C/O sudden loss
of vision 24 hours ago!
 Transient or persistent? Persistent
 Is it painless or painful? No ocular pain but
headache
 Describe your headache? Recent, Localized in
the temporal area
Mostly will be a case of Arteritic anterior
ischemic optic neuropathy (AION), giant cell
arteritis (GCA)
An emergency case for admission, Lab (ESR,
CRP, CBC), TAB
The prognosis is very poor, aim is to protect the
other eye (risk of involvement of the other eye
can be reduced from 95% to 10% by IV steroids)
GCA is a blinding disease with also risk of
mortality (stroke, MI, artery
occlusions/aneurysms)
Temporal artery
• Tender
• Pulseless

6. Sudden loss of vision
 Case scenario: 40 YO female patient C/O sudden
loss of vision 24 hours ago!
 Transient or persistent? Persistent
 Is it painless or painful? ocular pain, behind the
eye, worse on eye movement.
 Recurrence? +
Mostly will be a case of optic neuritis, MS.
MRI should be done to detect the chance of
clinical MS (multiple white lesions)
Not an emergency and according to ONTT, IV
steroids + oral (tapering) only hasten the recovery
but does not affect the final visual outcome.
Some studies here showed that IF beta 1 a
following the acute episode significantly reduced
the 3-year clinically definite MS in patient with 2
or more white lesions.
MS is disabling disease and patient might have
motor, autonomic and cerebellar symptoms.

7. Visual field loss
 50 YO patient C/O sudden blurring of
vision 3 days ago and discovered that he
lost his lower visual field.
Vascular ischemic factors? DM, HTN
Must be referred ASAP as he might have
RD, BRVO, .. But could be Non arteritic
AION (related to his ischemic risk factors)
Even in such a case, the 1st priority will be
to exclude GCA (ESR, CRP, CBC) + work up
for ischemic risk factors.

8. Visual field loss
 42 YO female patient C/O discovered loss
of both temporal fields.
 The site of lesion here is the optic chiasm
(chiasmal syndrome)
 In this age/gender, pituitary adenoma
comes 1st in the list of DD.
 Ask about: symptoms of ++ ICP (vomiting,
headache, tennitus ..), hormonal
disturbances (prolactin, GH, ACTH, TSH,
FS, LH)
Should be referred to ophthalmologist,
neurologist and endocrinologist.
Any visual field defect = MRI (except when
there is ocular finding)

9. Diplopia
 75 YO patient C/O seeing double suddenly
over the last 48 hours!
 Uniocular vs Binocular (double vision
disappears on covering one eye)? Binocular
 Persistent vs intermittent? Persistent
 Orientation? Horizontal
 Which gaze? Left
Left 6th cranial nerve palsy
Again urgent, GCA has to be excluded in this
age. Can present with cranial nerve palsy
(admission, ESR, CRP, CBC + vascular risk
factor > DM, HTN)

10. Diplopia
 62 YO patient C/O seeing double suddenly
over the last 48 hours which disappeared after
drooping of the Lt eyelid!
 Uniocular vs Binocular? Binocular
 Persistent vs intermittent? Persistent
 Orientation? Horizontal
 Which gaze? Primary position
Lt 3rd cranial nerve palsy
Again emergency, has to be seen by
ophthalmologist to exclude the serious
cerebral aneurysm which is life-threatening.

11. Diplopia
 8 YO boy C/O seeing double, over the last
week after he had fallen from height!
 Uniocular vs Binocular? Binocular
 Persistent vs intermittent? Persistent.
 Orientation? vertical
4th CN palsy vs orbital floor fracture
Urgent referral to ophthalmologist, trauma
team.
4th CN plasy will present with contralateral
head tilt, quiet
Orbital fracture will present with
enophthalmos, restricted up gaze +
nausea/vomiting/syncope.
Both conditions require CT brain/orbit
WEBOF is for immediate repair.

12. Diplopia
 46 YO female patient C/O seeing
double, ptosis over the last 6 months!
Uniocular vs Binocular? Binocular
Persistent vs intermittent? intermittent
Orientation? Horizontal
Which gaze? Primary position
Myasthenia Gravis
Has to be seen by ophthalmologist,
neurologist
Anytime might have respiratory distress
due to affection of respiratory muscles
(Emergency)

13. Other cranial nerve palsies: Facial
 78 YO patient C/O sudden deviation of the
mouth angle to the Lt, unable to close his
Rt eye.
 Rt facial palsy
 Ask about Hx of trauma, Sx, recurrence,
symptoms of ++ ICP
 Urgent referral: ophthalmologist (to
protect the eye), Neurologist to protect the
life (not all facial palsies are idiopathic-
Bells, but also might be serious codition as
CPA tumour)

14. Headache
 35 YO female patient C/O headache,
blurred vision!
Recent vs longstanding? Recent.
Diffuse vs localized? Diffuse.
Associated symptoms? ++ ICP
Simply > measure BP to exclude
malignant HTN
To be Referred ASAP to ophthalmologist,
Neurologist.
URGENT Neuroimaging to exclude SOL,
cerebral venous sinus thrombosis.
Normal BP, Normal neuroimaging > LP
(high opening pressure) >> IIH

15. Headache
 30 YO female patient C/O headache!
Recent? No, Longstanding.
Diffuse? No, unilateral, changing sides.
Criteria? Throbbing/boring head pain + nausea, vomiting!
+ Aura (visual disturbances – flashing lights, blurred
vision, or visual field defect lasting 15 to 50 minutes before
the migraine.
May experience temporary or permanent neurologic
deficits, such as paralysis, numbness, tingling.
Migraine!
To be referred to ophthalmologist to exclude papilledema.
Neurologist: Neuroimaging if atypical Migraine