Neuro-ophthalmology

Abdulrahman Al-Muammar
College of Medicine
King Saud University

Neuro-ophthalmology
Objectives:
Recognize and interpret the common signs and
symptoms of neuro-ophthalmic disorders

Obtain appropriate history

Measure visual acuity
Examine pupillary reaction
Test the function of the extraocular muscles
Evaluate the visual fields
Inspect the optic nerve head

Neuro-ophthalmology
Pupil
Ocular motor system
Visual system
Visual fields
Common neuro-ophthalmic disorders

Pupil
Pupillary size is determined by number
of factors including
Age
Level of alertness
Level of retinal illumination
Accommodative effort

Pupil
Anatomy of pupillary pathway
Afferent limb
Efferent limb
Parasympathetic pathway
Sympathetic pathway

Near response

Pupil

Pathway of pupillary reaction to light

Sympathetic pathway

Afferent pupillary defect (APD)

Afferent pupillary defect (APD)

Causes of APD
Optic nerve disease
Significant retinal disease
Amblyopia

Efferent pupillary defect

Anisocoria

Anisocoria

Anisocoria
Pupillary inequality greatest

In bright light
In dim light
(large pupil)
(small pupil)
3rd nerve palsy
Ptosis
Trauma
Horner syndrome
Tumor
Physiological
Temporal lobe herniation
Aneurysm
No 3rd nerve palsy
Drug induced
Adies pupil
Iris damage (trauma/surgery/laser)
Basal meningitis

Anisocoria

Horner syndrome

Ocular motor system

Ocular motor system

Ocular motor system

3rd nerve palsy

+ ve pupillary involvement
An incomplete III palsy which progress
Other neurological signs
No resolution in 3 months
Aberrant regeneration appears

Emergency
Do MRI,MRA
If negative do catheter angiography
To r/o compressive lesion: aneurysm, tumor
Other possible causes : vasculopathy, trauma, inflammatory,
demyelination, infectious, MG, congenital

Ocular motor system

4th nerve palsy

Most frequent cause is trauma
If no trauma, isolated 4th nerve palsy
then most likely vasculopathic ( Do BP,
BS)
+ve trauma, any other neurological
signs, normal BP/BS or palsy lasting >
3 months then MRI is needed.

Ocular motor system

6th nerve palsy

Isolated 6th nerve palsy most likely
vasculopathic ( do BP/BS)
Normal BP/BS, other neurological
signs, trauma, or palsy > 3 months then
do MRI

Visual system

Visual system

Visual system

Visual fields defect

Visual fields defect

Visual fields defect

Visual fields defect

Visual fields defect

Visual fields defect

Optic disc

Disc swelling
Mechanical signs
Elevation
Blurred margins
Peripapillary edema
Choroid folds

Vascular signs
Hyperemia
Venous dilation
Disc hemorrhage
NFL infarcts
Exudates

Causes of disc swelling

Increased intracranial pressure
Ischemic optic neuropathy
Optic neuritis
Central retinal vein occlusion
Nutritional optic neuropathy
Toxic optic neuropathy
ETOH-ethanol-DigitalisEthambutol -ChloramphenicolINH

Tumor
Infiltrative
Orbital Pseudotumor
Thyroid orbitopathy

Amaurosis Fugax
Transient monocular visual loss or dimming
May last from 2-3 minutes to 30 minutes or more
Due to decrease blood flow to the eye
Causes:
Carotid atheroma
Cardiac valvular disease
Atrial myxoma
Retinal migraine
Giant cell arteritis
Hyperviscousity syndromes

Myasthenia Gravis (MG)

Chronic auto-immune disorder characterized by
presence of antibodies which block the ACH
receptor sites
It can affect any muscle
Eye signs are the presenting signs in 50% of the
patients

Ptosis
Any ocular motility disturbances
INO
Variability is the hallmoark

Myasthenia Gravis (MG)

Diagnosis

Clinically
Pharmacologically (Tensilon test)
Serologically
Sleep test
Ice-pack test
CT chest
Thyroid function test
ANA

Treatment

Acetylcholinesterase inhibitors
Steroid
Immunosuppressant
Plasmapheresis
Thymectomy

Multiple sclerosis
Patients with multiple sclerosis (MS)
frequently have visual complaints
Cerebellar dysfunction
Motor symptoms
Sensory symptoms
Mental changes
Sphincter disturbances

Multiple sclerosis
Ocular complications:
Optic neuritis
Chiasmal and retro chiasmal abnormalities
Ocular motility disturbances

Treatment
Steroid
Interferon

Thank you