Review of neuro lecture
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![Page 1: Review of neuro lecture](https://reader036.fdocuments.us/reader036/viewer/2022062300/5549456ab4c905054d8b5495/html5/thumbnails/1.jpg)
Neuro-ophthalmology
Abdulrahman Al-Amri, MD
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Objectives• Anatomy& Physiology• Terminology
– Anisocoria: unequal pupil size– Papilledema
• Approach as GP• Pathology
– Optic neuropathy• Optic Neuritis
• Ischemic optic neuropathy (ION)
• GCA
• Nerve Palsies– 3rd,4th,6th nerve disorders
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Anatomy& Physiology
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Applied anatomy of Afferent & Efferent pupillary defect
Anatomical pathway Signs
•APD
•Loss or diminished reflex
(damaged II)3rd
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Efferent pupillary defect (EPD)
– III nerve palsy
– Sphincter pupillae• Loss of direct and
consensual (damaged III)
• Anisocoria
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Approach as GP
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Approach
History• Visual:
– Loss• Transient• Persistent
– Field defect• Pain • Diplopia
– Monocular:..• Tear film• Cornea and lens
– Binocular:…• Nerve palsies
• POH
• PMH:– MS– CTD– Gran. Dis– Drugs:Anti-TB
• SR– Headache
– Hearing
– Balance
– Speech
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Examination • Proptosis • Eyelid
– Ptosis– Lagophthalmos
• Nystagmus • EOM• VA(BCVA)• Color vision• Pupillary reflexes
– Afferent vs Efferent
• Disc– Edema
– Pallor
– Hyperemia
• Visual Field – Central scotoma
– Altitudinal
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Pathology
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Optic Neuritis• Age 20-50• Unilateral • Worsen over hrs/days
then Recovery starts• Retrobulbar pain..may
be worse on eye mov.
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• VA& Color vision
• RAPD
• Disc
– Edema
– Hyperemia (1/3 of cases)
Central scotoma
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Dx
Clinical
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Optic Neuritis
Causes • MS• Infectious
– Viral ..
• Toxic
– Investigate:
• CBC,ESR,CRP,
• CXR,Syphilis Serology
• ANA, LFT,U+E
• MRI– MS…
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RX:– Underlying – IV Steroid
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Ischemic optic neuropathyION
• Old
• Visual loss
• APD
• Disc edema
• Disc: Pallor…Hyperemic
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Hyperemic Disc Pale Disc
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IONNon-arteriticArteritic
IncidenceCommon
10/100,000
Rare
0.3/100,000
Cause Arteriosclerosis GCA
ESR& CRPNHigh
TAB-ve+ve
Risk to fellow eyeLow High
RxAspirin Steroid
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Papilledema • Malignant HTN
• SOL– Tumor
• Trauma– Cerebral edema/hage
• Pseudotumor cerebri (Idiop.Intracranial HTN)
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Papilledema Papillitis
• Bilateral• Gradual • Transient v. loss• Blind spot• Dye leakage-FFA• Symp of ICP• SOL on MRI
• Unilateral• Rapid • Profound• Central scotoma• Dye leakage-FFA• Symp of MS• Demyelinatin on MRI
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SteroidTetracyclineOCPNalidixic acidExcess-Vit A derivative
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OCULAR MOTOR NERVE PALSIES
1. Third nerve
2. Fourth nerve
3. Sixth nerve
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Anatomy of third nerveOculomotor nucleus
Pituitary gland
Carotid artery
Cavernous sinus
III nerveClivus
Basilar artery
Post cerebral artery
Red nucleus
Pons
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Applied anatomy of pupillomotor nerve fibres
Blood vessels on pia mater supply surface of the nerve including pupillary
fibres ( damaged by compressive lesions )
Vasa nervorum supply partof nerve but not pupillaryfibres ( damaged by medicallesions )
Pupillary fibres lie dorsal and peripheral
SurgicalSurgical
Medical
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Ptosis, mydriasis
• Limited depression • Limited adduction
• Normal abduction
• Limited elevation
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Right third nerve palsyRight third nerve palsy
PupilPupil? ?
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Watch
Describe what is happening
Where is the problem, and why?
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Anatomy of fourth nerve
• Only cranial nerve to emerge dorsally• Crossed cranial nerve• Very long and slender
Internal carotid artery
Postr. communicating artery
IIIVI
Postr.cerebral arterySupr.cerebellar artery
Basilar arteryIV
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Signs of right fourth nerve palsy
• Right overaction on left gaze
• Rt under action on depression in adduction • Vertical diplopia
• Rt hyperdeviation in primary position when left eye fixating• Excyclotorsion
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Rt 4th nerve palsy
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Anatomy of sixth nerve
Basilar artery
Pituitary gland
Carotid artery
Cavernous sinus
VI nerve
Petroclinoidligament
Clivus
Pyramidal tract
Vestibularnucleus
Mediallemniscus
4th ventricle
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Primary position Rt Gaze
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Straight in primary position due to partial recovery
Limitation of right abduction and horizontal diplopia
Normal right adduction
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DDxDDx Nerve palsyNerve palsy NMJNMJ
Myasthenia GravisMyasthenia Gravis
MuscleMuscle TEDTED
OrbitOrbit
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Problem solving
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33rdrd pupil problem pupil problem
Describe the signsWhere is the problem, and why?
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Describe the signsDescribe the signsWhere is the problem, and why?Where is the problem, and why?
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left
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Bright lightBright light PharmacologicalPharmacological Adie’s pupil Adie’s pupil TraumaTrauma
sphincter rupturesphincter rupture
III nerve palsyIII nerve palsy Unlikely if isolatedUnlikely if isolated
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Dim lightDim light PharmacologicalPharmacological UveitisUveitis Horner’s Horner’s
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