Download - Neuro-ophthalmology
Neuro-OphthalmologyNeuro-Ophthalmology
Dr.Lee Ming YuehDr.Lee Ming Yueh
Ophthalmology Unit, Penang HospitalOphthalmology Unit, Penang Hospital
Dr MYLeeDr MYLee
Neuro-Ophthalmlogy
Visual pathway & Visual field defect
Optic disc
Pupil
Cranial Nerve Palsy with eye manifestation
Visual Pathway & Visual Pathway & Visual Field DefectVisual Field Defect
Dr MYLeeDr MYLee
Type of Visual Field TestsType of Visual Field TestsConfrontation field testConfrontation field test- pick up > 75% of neurologic field defects- pick up > 75% of neurologic field defects
Kinetic PerimetryKinetic Perimetry - - GoldmannGoldmann perimeter perimeter test entire VFtest entire VF
Static PerimetryStatic Perimetry- - HumphreyHumphrey
Amsler Grid ChartAmsler Grid Chart- central visual field defect- central visual field defect
Dr MYLeeDr MYLee
Visual Pathway & Visual Pathway & Visual Field DefectVisual Field Defect
1. Optic nerve lesion- Ipsilateral total visual field defect
2. Chiasma Lesion- Bitemporal hemianopia
3. Post-Chiasma Lesion
- Homonymous hemianopia
Parietal lobe lesion – ‘pie on the floor’
Temporal lobe lesion – ‘pie in the sky’
The more posterior the lesion, the more congruous the visual field defect
Post-Chiasmal Lesion
Optic DiscOptic Disc
Dr MYLeeDr MYLee
Optic DiscOptic Disc
Optic disc oedemaOptic disc oedema
Optic atrophy, glaucomatous optic Optic atrophy, glaucomatous optic neuropathyneuropathy
Optic disc neovascularizationOptic disc neovascularization
Optic disc dysplasia/ hypoplasiaOptic disc dysplasia/ hypoplasia
Other optic disc abnormality: morning Other optic disc abnormality: morning glory, optic disc coloboma/pit extra…glory, optic disc coloboma/pit extra…
Dr MYLeeDr MYLee
Optic Atrophy
Causes:
traumaischemiatoxicinflammationglaucomahereditory
Optic Disc SwellingOptic Disc Swelling How do you approach? How do you approach?
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Optic nerve function tests:Optic nerve function tests:
Relative afferent pupillary defect (RAPD)Relative afferent pupillary defect (RAPD)
Visual acuityVisual acuity
Visual fieldVisual field
Colour visionColour vision
Contrast sensitivityContrast sensitivity
Visual evoked potentialVisual evoked potential
Dr MYLeeDr MYLee
Papilloedema Papilloedema vsvs Optic Neuritis Optic Neuritis
Dr MYLeeDr MYLee
PapiloedemaPapiloedema vsvs Optic NeuritisOptic Neuritis
Inflam of optic nerveInflam of optic nerve
Swollen disc (papilitis) Swollen disc (papilitis) or normal disc (retro-or normal disc (retro-bulbar).bulbar).
RAPD positiveRAPD positive
Impaired VAImpaired VA
Impaired colour vision, Impaired colour vision, red desaturationred desaturation
VF – VF – central scotomacentral scotoma
Raised ICPRaised ICP
Passive swelling of Passive swelling of disc secondary to disc secondary to ↑ICP↑ICP
No RAPDNo RAPD
VA – normalVA – normal early early stage, reduced late stage, reduced late stagestage
Normal colour visionNormal colour vision
VF - VF - ↑ blind spot↑ blind spot
Dr MYLeeDr MYLee
PapilloedemaPapilloedema
Investigations:Investigations:Blood pressureBlood pressureCT Scan/MRI to rule out space occupying CT Scan/MRI to rule out space occupying lesion (SOL)lesion (SOL)- brain- brain- orbit- orbitIf no SOL > lumbar punctureIf no SOL > lumbar puncture- Benign intra-cranial Hypertension- Benign intra-cranial Hypertension
Dr MYLeeDr MYLee
Causes of Optic NeuritisCauses of Optic Neuritis
InfectiveInfective
• Syphilis, leptospirosis, tuberculosis Syphilis, leptospirosis, tuberculosis
• viralviral
Non infective Non infective
• Demyellinating diseaseDemyellinating disease
• Post-immunizationPost-immunization
Dr MYLeeDr MYLee
Optic NeuritisOptic Neuritis
Investigation:Investigation: FBC, BUSE, RBSFBC, BUSE, RBS ESRESR VDRL, TPHAVDRL, TPHA Montoux Test, CXRMontoux Test, CXR Anti-Nuclear Ab, dsDNA Anti-Nuclear Ab, dsDNA Lumbar punctureLumbar puncture MRIMRI
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PupilPupil
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PupilPupil
• Controlled by Controlled by
- sphincter muscle- sphincter muscle
- dilator muscle- dilator muscle
1.1. SiteSite
2.2. SizeSize
3.3. ShapeShape
Dr MYLeeDr MYLee
Sphincter Muscle Sphincter Muscle Innervated by parasympathetic fibres Innervated by parasympathetic fibres origin. In the Edinger-Westphal (EW) origin. In the Edinger-Westphal (EW) nucleus.nucleus.Input that excites the EW:Input that excites the EW:
A.A. Light reflexLight reflex• Afferent neurons from retina to Pretectal Afferent neurons from retina to Pretectal
nucleus, to ipsilateral & contra-lateral Edinger nucleus, to ipsilateral & contra-lateral Edinger Westpal, parasympatatic outflow w CNIII to Westpal, parasympatatic outflow w CNIII to Ciliary ganglion > iris sphincter ms. Ciliary ganglion > iris sphincter ms.
B.B. Near SynkinesisNear Synkinesis• Triad- convergence, accommodation, miosisTriad- convergence, accommodation, miosis
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Dilator MuscleDilator Muscle
Innervated by sympathetic fibresInnervated by sympathetic fibres
3 neuron pathways:3 neuron pathways:
• 11stst order- post Hypotalamus > C8-T2 order- post Hypotalamus > C8-T2
• 22ndnd order- > Sup cervical ganglion order- > Sup cervical ganglion
• 33rdrd order- fol internal carotid artery and join order- fol internal carotid artery and join the ophthalmic division of CNV in the the ophthalmic division of CNV in the cavernous sinus > sup orbital fissurecavernous sinus > sup orbital fissure
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Pupillary PathwayPupillary Pathway
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Relative Afferent Pupillary DefectRelative Afferent Pupillary Defect
Causes:Causes:
• Optic neuropathyOptic neuropathy
• Total retinal detachmentTotal retinal detachment
• Dense vitreous haemorrhageDense vitreous haemorrhage
• Dense amblyopiaDense amblyopia
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Cranial Nerve Cranial Nerve pertaining pertaining to the Eyeto the Eye
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CN III PalsyCN III Palsy
Dr MYLeeDr MYLee
Clinical Features:Clinical Features:
PtosisPtosis
Divergent squint/ ExotropiaDivergent squint/ Exotropia
- paralysis of SR, MR, IR and IO muscle- paralysis of SR, MR, IR and IO muscle
- unopposed action of LR muscle- unopposed action of LR muscle
Pupil- can be dilated or not involvedPupil- can be dilated or not involved
- surgical or medical CNIII palsy- surgical or medical CNIII palsy
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Dr MYLeeDr MYLee
CN 3 PalsyCN 3 Palsy
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Surgical or Medical CN III Palsy?Surgical or Medical CN III Palsy?
Dr MYLeeDr MYLee
AetiologyAetiology
Congenital• Defect in the nucleus or motor portion of CNIII• Unilateral
Acquired• Vascular: Diabetes, Hypertension, smoking• Aneurysm, Space Occupying lesion• Trauma• Infective/ inflammation - meningitis • Miscellaneous: Multiple sclerosis, sarcoidosis
Dr MYLeeDr MYLee
InvestigationsInvestigations
CT scan/MRICT scan/MRI
Blood :Blood :• Full blood countFull blood count• Fasting blood sugar & lipidFasting blood sugar & lipid• ESRESR• VDRL & TPHAVDRL & TPHA• Serum ACE, CalciumSerum ACE, Calcium• ANA, ds-DNAANA, ds-DNA• Lumbar punctureLumbar puncture
Dr MYLeeDr MYLee
Management:Management:
Treat the underlying causeTreat the underlying cause
Persistent CNIII palsy:Persistent CNIII palsy:• Occlusion of the involved eyeOcclusion of the involved eye• Prism usually difficult and not effectivePrism usually difficult and not effective• Squint surgery- usually need correction of 3 Squint surgery- usually need correction of 3
muscles, risk of ocular ischemiamuscles, risk of ocular ischemia
Dr MYLeeDr MYLee
CN 4 PalsyCN 4 Palsy
Dr MYLeeDr MYLee
AetiologyAetiology
Congenital• Defect in the nucleus or motor portion of CN4• Unilateral / bilateral
Acquired• Trauma (70%)- bilateral• Vascular• Diabetes• Multiple sclerosis• Iatrogenic (SO tenotomy)
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Clinical Features
Abnormal head positionAbnormal head position• Face-turn to contralateral sideFace-turn to contralateral side• Head-tilt to contra-lateral sideHead-tilt to contra-lateral side
Ipsilateral hypertropia/ contra-lateral Ipsilateral hypertropia/ contra-lateral hypotropiahypotropia
Assoc ipsilateral Inferior oblique Assoc ipsilateral Inferior oblique overaction/ sup oblique underactionoveraction/ sup oblique underaction
Parks-Bielchowsky 3 steps testParks-Bielchowsky 3 steps test
Dr MYLeeDr MYLee
Hess ChartHess Chart
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Work-UpWork-Up
Clinical history most helpfulClinical history most helpfulFamily album tomography (FAT) scanFamily album tomography (FAT) scan
In acquired casesIn acquired cases-- TraumaTrauma
- SOL, aneurysm- SOL, aneurysm- Ischemic mono-neuropathy eg. Hypertension, diabetes, - Ischemic mono-neuropathy eg. Hypertension, diabetes, - infective /inflammatory eg. Syphilis, meningitis, - infective /inflammatory eg. Syphilis, meningitis, sarcoidosissarcoidosis
Dr MYLeeDr MYLee
InvestigationsInvestigations
CT scan/MRICT scan/MRI
Blood :Blood :• Full blood countFull blood count• Fasting blood sugar & lipidFasting blood sugar & lipid• ESRESR• VDRL & TPHAVDRL & TPHA• Serum ACE, CalciumSerum ACE, Calcium• ANA, ds-DNAANA, ds-DNA• Lumbar punctureLumbar puncture
Dr MYLeeDr MYLee
Management:Management:
MedicalMedical
• treat the underlying causetreat the underlying cause
SurgicalSurgical
• Indications of surgery:Indications of surgery:
- - diplopiadiplopia
- hypertropia interfere w binocular vision- hypertropia interfere w binocular vision
- abnormal head position- abnormal head position
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CN 6 PalsyCN 6 Palsy
Dr MYLeeDr MYLee
Clinical FeaturesClinical Features
Face turn to affected sideFace turn to affected side
Incommitant esotropiaIncommitant esotropia
Abduction deficit Abduction deficit
Horizontal diplopiaHorizontal diplopia
May be bilateralMay be bilateral
Fundus examination is mandatory!Fundus examination is mandatory!
Dr MYLeeDr MYLee
AetiologyAetiology
False localising sign – SOL not at the CN VIFalse localising sign – SOL not at the CN VI
* * tip of the petrous bone- petroclinoid ligamenttip of the petrous bone- petroclinoid ligament
TraumaTrauma
VascularVascular
Infective/inflammationInfective/inflammation
Demyellinating diseaseDemyellinating disease
Dr MYLeeDr MYLee
Aetiology in ChildrenAetiology in Children
CongenitalCongenital- - uncommon, must be excluded in all infantile uncommon, must be excluded in all infantile ETET- differential eg. Mobius synd, Duane- differential eg. Mobius synd, Duane
AcquiredAcquired• Tumour/ ↑ ICPTumour/ ↑ ICP• Infective/ inflammationInfective/ inflammation• AneurysmAneurysm
Dr MYLeeDr MYLee
Course of CN 6Course of CN 6
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Hess ChartHess Chart
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Work-UpWork-Up
CT/MRICT/MRIMedical work-upMedical work-up
• Full blood countFull blood count• Fasting blood sugar & lipidFasting blood sugar & lipid• ESRESR• VDRL & TPHAVDRL & TPHA• Serum ACE, CalciumSerum ACE, Calcium• ANA, ds-DNAANA, ds-DNA• Lumbar punctureLumbar puncture
Dr MYLeeDr MYLee
ManagementManagement
ConservativeConservative• OcclusionOcclusion• Fresnel prismFresnel prism
MedicalMedical• Botulinum toxinBotulinum toxin
SurgerySurgery- depends on LR function- depends on LR function
- wait for at least 6 months- wait for at least 6 months
- children may need early intervention to restore - children may need early intervention to restore BSVBSV
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Left CN 6 Palsy with Fresnel Prism on..Left CN 6 Palsy with Fresnel Prism on..
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Botulinum ToxinBotulinum Toxin
To avoid secondary MR contractureTo avoid secondary MR contracture
May not need surgeryMay not need surgery
If surgery indicated, recession of MR may If surgery indicated, recession of MR may not be needed (thus reduce risk of anterior not be needed (thus reduce risk of anterior ischaemic syndrome)ischaemic syndrome)
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CN VII PalsyCN VII Palsy
Dr MYLeeDr MYLee
CN VII PalsyCN VII PalsyUpper motor neuron lesionUpper motor neuron lesion
• Opposite to side of lesion, spare the foreheadOpposite to side of lesion, spare the forehead• Right CVA > L hemiparesisRight CVA > L hemiparesis
L UMNL CN VIIL UMNL CN VIIL homonymous hemianopiaL homonymous hemianopia
Lower motor neuron lesionLower motor neuron lesion• Ipsilateral to the lesionIpsilateral to the lesion• Causes of LMNL: Ramsay Hunt synd, parotid Causes of LMNL: Ramsay Hunt synd, parotid
tumourtumourDr MYLeeDr MYLee
Dr MYLeeDr MYLee
Course of CN VIICourse of CN VII
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Ophthalmology Concerns:Ophthalmology Concerns:
Lagophthalmos > exposure keratitisLagophthalmos > exposure keratitis
Dry eyeDry eye
Brow Ptosis Brow Ptosis
Lid laxity > ectropionLid laxity > ectropion
Dr MYLeeDr MYLee
Thank YouThank You
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