NEURO-OPHTHALMOLOGY. Clinical Examination Visual Acuity Colour Vision Visual Fields Pupils.
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Transcript of NEURO-OPHTHALMOLOGY. Clinical Examination Visual Acuity Colour Vision Visual Fields Pupils.
![Page 1: NEURO-OPHTHALMOLOGY. Clinical Examination Visual Acuity Colour Vision Visual Fields Pupils.](https://reader035.fdocuments.net/reader035/viewer/2022062217/56649e3f5503460f94b307ac/html5/thumbnails/1.jpg)
NEURO-OPHTHALMOLOGY
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Clinical Examination
• Visual Acuity• Colour Vision• Visual Fields• Pupils
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Normal Eye and Optic Disc
Cupped disc
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The swollen optic disc
•Papilloedema
•Papillitis
•Malignant hypertension
•Ischaemic optic neuropathy
•Diabetic optic neuropathy
•CRVO
•Intraocular inflammation
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25 y.o. femaleReduced VAPain with eye movementColour desaturationRAPD
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65 y.o. maleReduced VAPainless loss of visionEssential hypertensionSmoker
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The pale optic disc
•Congenital
•Secondary to
•raised ICP
•vascular retinal disease
•optic neuritis
•optic nerve compression
•trauma
•Glaucoma
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Papilloedema
• Disc swelling secondary to raised ICP• Headache
– Worse in the morning– Valsalva manouver
• Nausea and projectile vomiting• Horizontal diplopia (VI palsy)• Causes
– Space occupying lesion– Intracranial hypertension
• Idiopathic• Drugs • Endocrine
– Severe hypertension
Haemorrhages
CWS
Blurred optic disc margin
Small optic cup
Disc pallor
Vessel attenuation
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Pupils
• First Order – Retina to Pretectal Nucleus in B/S
(at level of Superior colliculus)• Second Order – Pretectal nucleus to E/W nucleus
(bilateral innervation!)• Third Order – E/W nucleus to Ciliary Ganglion• Fourth Order – Ciliary Ganglion to Sphincter
pupillae (via short ciliary nerves)
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Pupil
• Constricted (mioisis)– Sympathetic
(pupillodilator) denervation
– Drugs• Pilocarpine
• Morphine
• Dilated (mydriasis)– Parasympathetic
(pupilloconstrictor) denervation
– Lesion of the third CN
– Drugs• Atropine
• Cocaine
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Horner’s
• Oculosympathetic paresis
– Ptosis
– Miosis
– Ipsilateral anhidrosis
– Does not dilate with cocaine 4%
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Sympathetic Pathway
• First Order – Posterior Hypothalamus to
Ciliospinal centre of Budge (C8-T2)
(Uncrossed in Brainstem)• Second Order – Ciliospinal centre of Budge to
Superior Cervical Ganaglion• Third Order – Superior Cervical Ganglion to
dilator pupillae muscle. (Close to
ICA and joins V1 intracranially)
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Pancoast bronchogenic carcinoma
Otitis MediaTolosa-Hunt Sy.
CVATumour
Internal Carotid Dissection
Herpes Zoster
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Causes of Horner’s pupil• Central – B/S lesions (tumours, vascular and MS)
Syringomyelia, Lat. Med. Syn., S.C. ca.• Preganglionic – Pancoast tumour, Carotid & Aortic
aneurysms, Neck lesions/trauma.• Postganglionic – Cluster headaches, Nasopharyngeal
tumours, Otitis media, Cavernous
sinus mass and ICA disease.• Miscellaneous – Congenital (brachial plexus injury)
Idiopathic.
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• Argyll-Robertson pupil– Small, irreg
– Does not react to light
– Reacts to accommodation
– Causes• syphilis
• diabetes
• Miotonic pupil (Adie’s syndrome)– Dilated
– Poor response to light and convergence.
• Constricts with weak Pilocarpine
• Holmes-Adie syndrome– Reduced tendon reflexes
(Knee, ankle)
- Orthostatic hypotension
Afferent & efferent defects
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Ocular motility abnormalities
• Third nerve palsy– Double vision
– Eye turned down & out
– Ptosis
– Dilated pupil & headache
• Compressive lesion
• Sixth nerve palsy– Double vision
– Eye turned in
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Cranial Nerve PalsiesLooking straight ahead
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Posterior communicating artery aneurysm
III CN
Posterior cerebral artery
Chiasma
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Internuclear Ophthalmoplegia
• Defective adduction of the ipsilateral eye
• Nystagmus of the contralateral (abducting) eye
• NORMAL CONVERGENCE• Causes
– Young patients• Bilateral • Demyelination
– Older patients• Unilateral• Vascular, tumours
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Myasthenia Gravis
• Fatigability
• Double vision
• Lid twitch
• Ptosis
• Normal reflexes & sensation
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INVESTIGATIONS MG
• Anti ACh receptor Ab’s
• Electromyography
• Tensilon test
– Edrophonium blocks acetyl-cholinesterase
– Beware of cholinergic cardiac effects. Use with Atropine 0.6mg
• Thoracic CT and MRI to rule out thymoma
Anti AChR Ab’s
AChR
ACh
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Localising the lesion
• Monocular visual field defects indicate lesions anterior to the optic chiasm
• Bitemporal defects are the hallmark of chiasmal lesions
• Binocular homonymous hemianopia result from lesions in the contralateral postchiasmal region
• Binocular quadrantanopias reflect optic tract lesions
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