Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery www.PacificSpecialists.com 9/19/2018

… nothing to disclothes … Howard R Krauss, MD Los Angeles, CA

Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery Pacific Eye & Ear 11645 Wilshire Blvd., Suite 600 Los Angeles, Ca. 90025 310-477-5558 DrKrauss@PacificSpecialists.com www.PacificSpecialists.com Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery www.PacificSpecialists.com 9/19/2018

pacific eye & ear Pacific Eye & Ear is an association of eleven doctors, providing medical and surgical services encompassing Ophthalmology, ENT, Facial Plastic Surgery and Audiology. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision 1) Talk with and examine the patient www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision When the vision is subnormal, proceed to: 2) Pinhole acuity 3) Refraction 4) Visual field assessment www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If corrected acuity is normal and visual field is normal: 1) Complete the general examination and if all else is normal, proceed to discussion of optical services, from spectacles to contact lenses to surgery. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If corrected acuity is abnormal or visual field is abnormal: 1) Proceed with Retinal Evaluation and/or consultation. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If Retinal Consultant detects abnormalities and arranges treatment for same: 1) Re-evaluate patient to assess whether or not the retinal abnormalities are likely the only source of the patient’s complaints. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, crystalline lens, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www.PacificSpecialists.com 9/19/2018

Diagnostic approaches to reduced vision If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www.PacificSpecialists.com 9/19/2018

Ocular Coherence Tomography (OCT) Neuro-ophthalmic Applications Evaluation and Monitoring: MS / Optic Neuritis Ischemic Optic Neuropathy Any Optic Neuropathy Compressive Optic Neuropathy Papilledema

55-year-old woman with MS BCVA 20/30 OD 20/25 OS

47-year-old Hawaiian woman Aware of diminishing vision of the left eye over 1 year, rapidly worsening over the last 3 months. Intermittent mild pain OS, especially when flying. 47-year-old Hawaiian woman www.PacificSpecialists.com

Visual Acuity 20/25 OD 20/50-1 OS No proptosis No enophthalmos No hyper- or hypoglobus Orthophoric in all positions Full ductions 2+ RAPD OS Visual Acuity 20/25 OD 20/50-1 OS www.PacificSpecialists.com

Humphrey 10-26-11 www.PacificSpecialists.com

Octopus 12-27-11 www.PacificSpecialists.com

RNFL thkns 106 OD, 93 OS www.PacificSpecialists.com

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Transnasal Image-Guided Orbital Surgery (TIGOS) TIGOS has been carried out by Drs. Krauss & Griffiths since 2001. The work was presented at the 5th International Congress of the World Federation of Skull Base Societies in 2008. www.PacificSpecialists.com 9/19/2018

Outpatient Surgery www.PacificSpecialists.com

Image-guided Endoscopic Sx www.PacificSpecialists.com

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Pre-op / Octopus / Post-op www.PacificSpecialists.com

Post-op www.PacificSpecialists.com

2 weeks post-op UCVA 20/25 Trace RAPD OS Mild weakness of left adduction and infraduction – improving day- by-day 2 weeks post-op www.PacificSpecialists.com

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mri of the visual afferent system Brain and Orbits with and without contrast www.PacificSpecialists.com 9/19/2018

mri of the visual afferent system If you know the lesion is retrogeniculate: Brain with and without contrast www.PacificSpecialists.com 9/19/2018

mri of the visual afferent system If you know the lesion is anterior visual pathway: Orbits and pituitary with and without contrast www.PacificSpecialists.com 9/19/2018

BSB 54yo female 11/05: Puffiness OS Va 20/15,20/25 Ext: H 16/21 P: 1.2log LAPD EOM: min ↓ L elev

BSB – W/U OCT NFL (11/05):

BSB – W/U MRI (12/05):

BSB – F/U MRI (5/06):

BSB – F/U 10/06: Diplopia in right gaze Va 20/20 OU Ext: H 16/14 EOM: min ↓ L add P: .3log LAPD

BSB – W/U OCT NFL (10/06):

JWD 63yo male 3/06: ↓Va OS Va 20/20,20/60 P: .9log LAPD

JWD – POH 12/05: Routine check vision Dx: “cataracts” Referred for cataract extraction Ophthalmologist said “no cataract”

JWD – W/U OCT:

JWD – F/U 8/07: “No Δ” Va 20/25 OU P: .9log LAPD

JWD – W/U OCT NFL (8/07):

KH 48yo female 11/08: ↓Va Va 20/30,8/200 VF: Ext: w/q P: .3log LAPD EOM: full SLE: wnl Fundus: nl DMV www.PacificSpecialists.com 9/19/2018

KH – PMH 1/08: Polydipsia 4/08: Amenorrhea 10/08: HA, N/V www.PacificSpecialists.com 9/19/2018

KH – W/U OCT NFL (11/08): www.PacificSpecialists.com 9/19/2018

KH – W/U MRI (11/08): www.PacificSpecialists.com 9/19/2018

11/08: Transphenoidal endoscopic decompression Path: craniopharyngioma KH – Rx 11/08: Transphenoidal endoscopic decompression Path: craniopharyngioma www.PacificSpecialists.com 9/19/2018

KH – F/U 8/09: “Better” Va 20/20 OU N 3pt OU VF: Ext: w/q P: w/o APD EOM: full SLE: wnl Ta: 19/22 Fundus: www.PacificSpecialists.com 9/19/2018

KH – W/U OCT NFL (8/09): www.PacificSpecialists.com 9/19/2018

In summary: Listen to the patient and solicit information. Examine the patient: determine BCVA and assess VF. Understand and explain symptoms and findings. Consider and recommend additional testing, or consultation, as indicated. Follow-up on all tests and consultations with patient. Avoid contributing to a delay in diagnosis and treatment.

Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery Pacific Eye & Ear 11645 Wilshire Blvd., Suite 600 Los Angeles, Ca. 90025 310-477-5558 DrKrauss@PacificSpecialists.com www.PacificSpecialists.com Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery www.PacificSpecialists.com 9/19/2018