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

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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

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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…

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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

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Papilloedema Papilloedema vsvs Optic Neuritis Optic Neuritis

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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

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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 muscledilator muscle

1.1. SiteSite

2.2. SizeSize

3.3. ShapeShape

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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

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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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CN 3 PalsyCN 3 Palsy

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Surgical or Medical CN III Palsy?Surgical or Medical CN III Palsy?

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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

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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

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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 positionabnormal head position

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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

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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

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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

Dr MYLeeDr MYLee

Neuro-ophthalmology

Health & Medicine

Transcript of Neuro-ophthalmology