Disorder Of The Eyes
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Transcript of Disorder Of The Eyes
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Resident’s TutorialDisorder of the eyes I
Piti Niyomsirivanich ,MD.
•Episode IThe Human visual systemClinical Assessment of Visual Function
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Outline
• Episode I– The Human visual system– Clinical Assessment of Visual Function
• Episode II– Disorders– Transient or sudden visual loss– Diplopia
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Take home message
• Retinogeniculatecortex pathway– RetinaOptic nerveOptic chiasmOptic tractLateral
geniculate bodyPrimary visual cortex• Pupils response pathway
– Retina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary NucleiEdinger-Wesphal NucleiCN IIICiliary GanglionCiliary muscle
• Refractory defect : pinhole : Rx glasses , LASIK• VA : snellen chart ,rosenbaum card , FC HM LP • color blindness : Ishihara color plate :red,green• Stereopsis : Random dot stereogram , polarized image• Visual field : RetinaOptic nerveOptic chiasmOptic
tractLateral geniculate bodyPrimary visual cortex
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Take home message
• Retinogeniculatecortex pathway– RetinaOptic nerveOptic chiasmOptic tractLateral
geniculate bodyPrimary visual cortex• Pupils response pathway
– Retina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary NucleiEdinger-Wesphal NucleiCN IIICiliary GanglionCiliary muscle
• Refractory defect : pinhole : Rx glasses , LASIK• VA : snellen chart ,rosenbaum card , FC HM LP • color blindness : Ishihara color plate :red,green• Stereopsis : Random dot stereogram , polarized image• Visual field : RetinaOptic nerveOptic chiasmOptic
tractLateral geniculate bodyPrimary visual cortex
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Take home message
• Retinogeniculatecortex pathway– RetinaOptic nerveOptic chiasmOptic tractLateral
geniculate bodyPrimary visual cortex• Pupils response pathway
– Retina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary NucleiEdinger-Wesphal NucleiCN IIICiliary GanglionCiliary muscle
• Refractory defect : pinhole : Rx glasses , LASIK• VA : snellen chart ,rosenbaum card , FC HM LP • color blindness : Ishihara color plate :red,green• Stereopsis : Random dot stereogram , polarized image• Visual field : RetinaOptic nerveOptic chiasmOptic
tractLateral geniculate bodyPrimary visual cortex
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Take home message
• Retinogeniculatecortex pathway– RetinaOptic nerveOptic chiasmOptic tractLateral
geniculate bodyPrimary visual cortex• Pupils response pathway
– Retina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary NucleiEdinger-Wesphal NucleiCN IIICiliary GanglionCiliary muscle
• Refractory defect : pinhole : Rx glasses , LASIK• VA : snellen chart ,rosenbaum card , FC HM LP • color blindness : Ishihara color plate :red,green• Stereopsis : Random dot stereogram , polarized image• Visual field : RetinaOptic nerveOptic chiasmOptic
tractLateral geniculate bodyPrimary visual cortex
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Take home message
• Retinogeniculatecortex pathway– RetinaOptic nerveOptic chiasmOptic tractLateral
geniculate bodyPrimary visual cortex• Pupils response pathway
– Retina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary NucleiEdinger-Wesphal NucleiCN IIICiliary GanglionCiliary muscle
• Refractory defect : pinhole : Rx glasses , LASIK• VA : snellen chart ,rosenbaum card , FC HM LP • color blindness : Ishihara color plate :red,green• Stereopsis : Random dot stereogram , polarized image• Visual field : RetinaOptic nerveOptic chiasmOptic
tractLateral geniculate bodyPrimary visual cortex
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Take home message
• Retinogeniculatecortex pathway– RetinaOptic nerveOptic chiasmOptic tractLateral
geniculate bodyPrimary visual cortex• Pupils response pathway
– Retina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary NucleiEdinger-Wesphal NucleiCN IIICiliary GanglionCiliary muscle
• Refractory defect : pinhole : Rx glasses , LASIK• VA : snellen chart ,rosenbaum card , FC HM LP • color blindness : Ishihara color plate :red,green• Stereopsis : Random dot stereogram , polarized image• Visual field : RetinaOptic nerveOptic chiasmOptic
tractLateral geniculate bodyPrimary visual cortex
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Take home message
• Retinogeniculatecortex pathway– RetinaOptic nerveOptic chiasmOptic tractLateral
geniculate bodyPrimary visual cortex• Pupils response pathway
– Retina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary NucleiEdinger-Wesphal NucleiCN IIICiliary GanglionCiliary muscle
• Refractory defect : pinhole : Rx glasses , LASIK• VA : snellen chart ,rosenbaum card , FC HM LP • color blindness : Ishihara color plate :red,green• Stereopsis : Random dot stereogram , polarized image• Visual field : RetinaOptic nerveOptic chiasmOptic
tractLateral geniculate bodyPrimary visual cortex
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Human visual system
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Human visual system
• Retina– Part of brain– Serve as transducer– Two type of receptor
• Rod scotopic (dim)• Cone photopic (day)
– Cone Fovea (exclusively)
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Light
Rod Cell
Cone Cell
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Light
Amacrine Cell
Horizontal Cell
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Light
Ganglion Cell
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Light
Optic disc Optic nerve
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Optic nerve
Retinogeniculatecortex pathway
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Optic Chiasm
Retinogeniculatecortex pathway
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Optic Tract
Retinogeniculatecortex pathway
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Lateral geniculate bodysynapseRelay station
Retinogeniculatecortex pathway
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Primary visual cortex
Retinogeniculatecortex pathway
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RetinaOptic nerveOptic chiasmOptic tract
Lateral geniculate body(Synapse , relay station)
Primary visual cortex
Retinogeniculatecortex pathway
Rod , coneAmacrine Horizontal cell
Ganglion cell
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Pupil responseRetina (ganglion cell)Optic nerveOptic chiasmOptic tract
ไม่�ผ่�าน Lateral geniculate body
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Pupil responseRetina (ganglion cells)Optic nerveOptic chiasmOptic tract
Pretectal Olivary NucleiSynapse
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Pupil responseRetina (ganglion cells)Optic nerveOptic chiasmOptic tract
Pretectal Olivary NucleiSynapse
Edinger-Wesphal Nuclei Synapse
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Pupil responseRetina (ganglion cells)Optic nerveOptic chiasmOptic tract
Pretectal Olivary NucleiSynapse
Edinger-Wesphal Nuclei Synapse
CN III
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Pupil responseRetina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary Nuclei
SynapseEdinger-Wesphal Nuclei SynapseCN IIICiliary Ganglion
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Pupil responseRetina (ganglion cells)Optic nerveOptic chiasmOptic tractPretectal Olivary Nuclei
SynapseEdinger-Wesphal Nuclei SynapseCN IIICiliary GanglionCiliary muscle
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Clinical Assessment of Visual Function
Refractory State
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Emmetropia
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Hyperopia
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Astigmatism
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Presbyopia
• Middle age
• Unable to increase refractory power to accomodation
• Reading glasses / Bifocal
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• Refractory Errors– Develop slowly stable adolescence
• Diabetes mellitus Sudden myopia – Hyperglycemia induced corneal edema
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Testing
• Pinhole aperture– Better through a pinhole refractory error
Treatment• LASIK
• glasses
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Clinical Assessment of Visual Function
Refractory State
Visual acuity
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Snellen chart
• Distance 6 m (20 ft)
• Rosenbaum card (36 cm) (14 in)
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• Distance 36 cm – (14 inches)
• Normal 20/20
• VA < 6/240– Finger counts– Hand motion – Light perception
Rosenbaum card
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Clinical Assessment of Visual Function
Refractory State
Visual acuity
Pupils
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Pupils
• Should be test in dim light
• Fixing on a distant target
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Light response
Y
Near response
N
No need to test‘near response’
Y
Normal Light-Near dissociation
N
•Argyll Roberson pupil (neurosyphilis)•Pineal region tumors•Obstructive hydrocephalus•Adies’s tonic pupil
RAPD
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• No light pupillary response Marcus Gunn pupil
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Anisocoria
• Anisocoria (asymetrical pupil up to 0.5 mm)
normal person constant as ambient varies
• DDX– Horner’s syndrome– Brainstem stroke – Carotid dissection
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• Mydriasis (Acute pupil dilatation)– Infection (Herpes zoster, influenza)– Trauma (blunt, penetrating, surgical)– Ischemia (diabetes , temperal arteritis)
• Tonic pupil ==> เอาไฟฉายออก แล้�วม่�านตาขยายช้�าล้ง– Adie’s syndrome (Tonic pupil + absent DTR)– Shy-Dragger syndrome (PD + MSA)– Diabetes , amyloidosis , segmental hypohidrosis
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Bilateral pupils abnormal
• Miosis– Medications (Narcotics: Morphine, Heroine)– Parasympathetics agents (pilocarpine ,demecarium
bromide)
• Mydriasis– Anticholinergic (Scopolamine)
• Unexplained abnormality Slit lamp examination– Trauma,FB adhesions , close angle glaucoma ,
intraocula inflammation
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Clinical Assessment of Visual Function
Refractory StateVisual acuity
PupilsEye movements And Alignment
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Eye Movements and Alignment
• Corneal light reflex
• Cover Test
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Stereopsis
Two eyes = 3D
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Stereopsis test
Polarized imageRandom dot stereogram
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Color vision
• Three classes of cones – Red (560 nm) X chromosome– Green (530 nm) X chromosome– Blue (430 nm) chromosome 7 rare
• Shift in peak spectral sensitivityAltering the proportion of primary colorColor mismatchdiscrimation between 2 color are impaired• Ishihara color plate (red-green color blindness)
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• Acquired color blindness– Bilateral stroke involving the ventral portion of
occipital lobe (cerebral achromatopsia) perceive only gray shadesdifficulty recognizing faces (prosopagnosia)
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Visual fields
• Mapping– Visual confronation– Quantitative visual
field mapping
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Visual field defect
Macula damage
GlaucomaOptic neuritis
(destroy axon of optic disc)
Turkish scimitar
Ischemic optic neuropathy
Horizontalmeridian
Optic neuritisToxic metabolicnutrition
macula
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Next episode
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Thankyou