NEURO-OPHTHALMOLOGY

Dr Mahmood FauziASSIST PROF OPHTHALMOLOGY

AL MAAREFA COLLEGE

OBJECTIVES Define the term ‘Neuro-Ophthalmology’ Describe the characteristics of normal

fundus, optic disc, Identify Selected optic nerve diseases

Neuro-ophthalmology is the sub-specialty of both neurology and ophthalmology concerning visual problems that are related to the nervous system Some commonly seen diseases that a neuro-ophthalmologist

may see include optic neuritis, optic neuropathy, papilledema, Optic atrophy

Visual light pathway

Visual acuity

Confrontation visual fields

Pupil size and reaction Efferent vs Afferent (Marcus Gunn) problem

Ocular motility Strabismus, limitation and nystagmus

Fundus exam Optic nerve swelling and spontaneous venous pulsations

NEURO-OPHTHALMIC EXAM

VISUAL FIELD

confrontation

Kinetic perimetry Static perimetry

SELECT NEURO-OPTH. CONDITIONS

OPTIC NERVE DISEASE Non-Arteritic Ischemic Optic Neuropathy (NAION)

Vascular disorder Pale, swollen disc +/– splinter hemorrhage Loss of VA , VF ( often altitudinal )

Arteritic Ischemic Optic Neuropathy (AION) Symptoms of giant cell arteritis ESR, CRP, Platelets +/– TABx Rx : systemic steroids

SELECTED OPTIC NERVE DISEASES Papillitis/Anterior Optic

NeuritisUnilateral edema, hemorrhage Consider

inflammatory

OPTIC NERVE DISEASE

Optic neuritis Idiopathic or associated with multiple sclerosis Young adults Decreased visual acuity and colour vision RAPD Pain with ocular movement Bulbar (disc swelling) or retrobulbar (normal disc)

Traumatic optic neuropathy Direct trauma to optic nerve Indirect : shearing force to the vascular supply

SELECTED OPTIC NERVE DISEASES

Congenital Anomalous Disc Elevation Absence of edema, hemorrhage Presence of SVP Consider:

Optic disc drusen Hyperopia

SELECTED OPTIC NERVE DISEASE Ischemic Optic Neuropathy

Pallor, swelling, hemorrhageAltitudinal Visual Field Loss

SICKLE CELL ANEMIA SC and S Thal more likely to have eye

involved Arteriolar occlusion

intravasc sickling hemolysis hemostasis thrombosis capillary non-perfusion

Similar to diabetes – poor perfusion = retinal ischemia neovascularization

Laser Tx – can prevent vision loss

THE SWOLLEN OPTIC DISC

Swelling of optic nerve head other than raised intra cranial pressure•Papillitis•Malignant hypertension•Ischaemic optic neuropathy•Diabetic optic neuropathy•CRVO•Intraocular inflammation

PAPILLOEDEMA Disc swelling secondary to raised

ICP Absence of SVP Usually bilateral Unilateral papilledema suggest orbital

pathology, such as an optic nerve glioma.

Headache Worse in the morning Valsalva manouver

Nausea and projectile vomiting Horizontal diplopia (VI palsy) Causes

Space occupying lesion Intracranial hypertension

Idiopathic Drugs Endocrine

Diffuse cerebral edema Severe hypertension Obstruction of CSF absorption as in

meningitis

Haemorrhages

CWS

Blurred optic disc margin

Small optic cup

Disc pallor

Vessel attenuation

CONGENITAL ANOMALOUS DISC ELEVATION

Absence of edema, hemorrhage Presence of SVP Consider:

Optic disc drusen Hyperopia

Fundus

• hyperemia of the optic disk and

large veins(early signs)

• edema (nearly more than 3D)

(common)blurring of the disk margins

(common)• filling of the physiologic cup

(common)

PAPILLITIS

SELECTED OPTIC NERVE DISEASE Optic Atrophy: Pallor of optic disc due to damage of retinal ganglion cells. Optic atrophy

occurs four to six weeks after cell damage due to reduced blood circulation or inflammation

Types: Primary: pallor occurs without prior optic disc swelling, and is due to retro bulbar damage of optic nerve up to lateral geniculate body. Color of Disc is chalky white with well defined margins.

Secondary: optic disc swelling is seen prior to pallor, margins may appear less defined, and color appears dirty white to grey. consecutive: consequence of diffuse retinal disease and findings are as in secondary optic atrophy. Consider:

Glaucoma Previous optic neuritis Previous ischemic optic neuropathy Long-standing papilledema Optic nerve compression by a mass lesion Retinitis pigmentosa