Girls work from
Dr.Sameer jamal lectures records
• It’s the since that study health and disease of the brain and the
cranial nerves that involved with the eye.
• We have 7 CN that involved (2-8)
II Optic vision
III Oculomotor eyelid and eyeball movement
innervates superior oblique
turns eye downward and laterally
face & mouth touch & pain
VI Abducens turns eye laterally
controls most facial expressions
secretion of tears & saliva
Important topics :
• Optic nerve swelling
• CN palsy.
• Anisocoria: it’s an unequal size of the pupils.
- It can be :
(due to that reason we should see the size and symmetry of the pupils on examination)
Major causes of Anisocoria:
- 3rd CN palsy (neurological disease give us a big pupil)
- horner's syndrome (neurological disease give us a small pupil)
NB: how to differentiate between them ?
3rd CN palsy:
-Limitation of the eye movement
-Pupil and other muscles are affected.
horner's syndrome :
- only ptosis
- Intact motility
Common causes of Anisocoria:
• pt. may takes pupil dilation drops as in Iritis( to make the iris not stick
to the lens)
• drops that used at clinic for fundoscopy examination.
• pt. used pilocarpine for Glaucoma it will constrict one eye and dilate
the other eye.
2- Trauma : particularly surgical trauma is more common than the non
- So if there’s no history of Drugs used or trauma that means Anisocoria
is due one of the major causes and it’s serious.
- Decrease visual acuity.
- Visual field changes.
- Dyschromatopsia: color vision changes.
NB: when pt. complain of disturbance in vision think 1st of the common diseases and use
the pin whole test , if the pt. vision get better so it’s RE.
But if it’s not it means it’s organic ( neurological or media البصرية الوسائط عتم )
- Media ( cornea , lens and vitreous ) , the Red reflex test by the ophthalmoscope it will
appear abnormal if the media was affected.
- Neurological ( optic nerve , retina , chiasm , visual pathway)
We have :
- Anterior visual pathway:
Retina + ON the loss will be in the same side.
- Posterior visual pathway:
Chiasm and beyond that it must be bilateral loss.
• So , Bilateralism + visual field changes + color vision changes = indication of
neurological visual loss
• As a GP u have to recognize and differentiate between :
1- ON swelling 2- ON atrophy
3- ON cupping.
3rd nerve palsy
If the patient had paralysis of the eye muscles he will complain of :
- Symptoms :
1- binocular diplopia: it’s apathognomonic for paralysis. الحاجة يشوف مفتوحة عينو تكون لما المريض يعني
واحد يشوفها مغمضة تكون ولما اثنين
2- abnormal head posture (AHP) : it’s not pathognomonic.
1- AHP (it’s symptom and sign)
3- hypotropia الرابع عكس نازلة العين
4- limitation of eye movment
5- incomitance it’s a (pathognomonic جدا )مهمة
الحول مختلفة اتجاهات في يطالع لما حول عندو الي المريض اما الجهات كل في يطالع لما متوازية تكون عينو الطبيعي االنسان
يكون ده يتغير
يكون ده االنحراف وبنفس مختلفة اتجاهات في طالع لو اما
شلل مو يعني
90 % of squint pt. not havingparalysis
10 % of them having paralysis
NB: in 3rd nerve palsy u have to take the age and pupil of the pt. into ur consideration.
- In young pt. with 3rd n palsy is intracranial aneurysm until prove otherwise. So u have to admit
the pt. regardless the pupil is on or off
4th CN palsy
• Symptoms :
- binocular diplopia
- Hypertopia الثالث عكس (due to superior oblique
muscle paralysis لما لتحت العين تسحب وظيفتها هيا
لفوق حتطلع العين تنشل
- Sings: الثالث حق نفسها
- Most of them are congenital
5th CN palsy
• hyposthesia (less sensation)
• Hypersthesia (hypersensitivity in the area of
distribution of ophthalmic division of trigeminal
• Spontaneous idiopathic pain without reason
6th CN palsy
• Limitations of abduction
• 50% of the pt. with 6th nerve palsy is due to intracranial tumor. So
as a GP you have to look for any brain tumor or papilledema.
7th CN palsy
• Lagophthalmous. عينو يقفل مايقدر المريض
Because orbicularis muscle is supplied by facial
• Tears all the time .
NB: you have to lubricate the pt. eye to avoid
dryness and loss of vision.
8th CN palsy
- Imbalance it may be due to ( ocular,
neurological, vestibular) causes.
- It’s rare due to ocular.
• It’s :
- Rhythmic : بإستمرار الحركة نفس تسوي العين
- Oscillation : tremor of the eye
- Of one or both eye.
Sensory Motor Neurological
-Vision loss due to disease
in the eye.
- begin in childhood
- responsibility of the
- no oscillopsia
-The motor system is
-begin in childhood
- responsibility of the
- no oscillopsia
-It can start at childhood
but it’s usually acquired
due to ( infections or
- as an ophthalmologist I
have to make sure it’s not
due to sensory or motor)
• Our rule as GP we have to make sure that the pt. with Nystgmus is
not due to neurological causes by :
1- onset: if it’s new it may be neurological.
2- oscillopsia: مهزوزة كلها الصورة نفس الدوخة زي مو مهزوزة الدنيا يشوف
3- vertical Nystagmus: is more likely to be neurological than
- Majority of pt. have horizontal Nystagmus.
4- primary position Nystagmus.
- In gaze position Nystagmus is less serious than primery.
NB: in gaze position الجنب على يكون المريض لما اشوفها يعني
DD of ON swelling:
All of them will complain of headache & pain.
1- malignant hypertension:
- As a GP u have to take the BP of the pt. by ur self if it was
high it confirm the diagnosis.
- so., u have to call the medicine department and refer the
pt. for them to stabilize his Bp.
( high Bp or sudden drop of Bp it will damage the optic
- When the Bp of the pt. get stabilized we have to refer the
pt. to the ophthalmologist before six weeks to make sure
of the ON Is back to the normal. ضغط ينزل لما كمان ممكن الن
العين على يأثر الدم
- If the pt. was normal so we have another three DD to think
2- Ischemic optic neuropathy 3- Ischemic optic Neuritis.
The both have (loss of vision , visual field loss and pupil abnormalities).
- We have to refer the pt. to the ophthalmologist directly.
How to differentiate between them ?
By the age
45 years and more
-With elderly pt. you have to order ESR and
CRP before call the opthalmologist to see if
the pt. have temporal arteritis, because it’s
a serious condition and it may make the
patient permanently blind within 2 weeks.
- فيها مثال اليمين العين لو يعني
اسبوعين خالل وحدة عين في يتعمي ممكن المريض
40 and less
If the pt. doesn’t have visual loss or high BP so we think of
• It’s unilateral or bilateral ON swelling due to increased IOP by
(tumor, infection or hemorrhage…ect).
- This pt. will need CT or MRI first.
- Then LP (because of coning) عملت وانا ورم عندو المريض لو عشان
يحصلو ممكن مااتأكد قبل
- If any thing appear abnormal u have to refer the pt. to the
- If the pt. was normal after the CT and LP so it may be
pseudotumor cerebri, confirm it by “CSF opening pressure”.
NB: when u do LP take CSF tap + opening pressure
The normal CSF pressure for adult (200 ml water or 20 cm )
- If the pt. have pseudotumor cerebri you have to call the
ophthalmologist. Because ON swelling if it left untreated for 4-
6 weeks it will result in optic atrophy then permanent
Sings of ON swelling (ophthalmoscope)
- You must have more than one sign to diagnose ON swelling:
1- sensation of elevation.
Focus retina and fuzzy optic
2- blurred margin
3- hemorrhage in nerves.
4- white exudates.
5- absent of the cup.
6- absent spontaneous nerve
• Pale color for the optic disk is
the characteristic feature of
- Because the blood vessel in
the ON when it dies it
- ON atrophy is the end stage
of all ON diseases , it will lead
to permanent loss.
- The most common optic
neuropathy that cause optic
atrophy is Glaucoma.
• Cup is devoid of nerve
• In glaucoma this white area
will increase in size because
the nerve fibers will die in
the RIM and the blood
vessel it will become white
>> enlarged cup
صور على شرحها معلومات
• AHP is whole mark for paralytic squint.
• Vestibulo ocular response: is a reflex eye movement that
stabilizes images on the retina during head movement
by producing an eye movement in the direction opposite
to head movement, thus preserving the image on the
center of the visual field
• عندو عشان لليمين مايل راسو واحد صورة على شرحها الدكتور
Rt. Lateral rectus palsy (6th n palsy)
• Most common cause of AHP in children and young adult
without trauma is paralytic squint.
• Head tilt is noticed by the Ear but the face turn noticed