إِنَّكَ أَنتَ الْعَلِيمُ الْحَكِيمُ } Neuro-ophthalmology اعوذ بالله من الشيطان الرجيم {قَالُواْ سُبْحَانَكَ لاَ عِلْمَ لَنَا إِلاَّ مَا عَلَّمْتَنَا إِنَّكَ أَنتَ الْعَلِيمُ الْحَكِيمُ } 1/14/2019 MAHGOUB SALEEM

MAHGOUB SALEEM ASSOCIATE PROFESSOR Neuro-ophthalmology MBBS (U of K) , DORCS (Eng.) , MRCOphth (UK), FRCOphth (UK) , FICS , FACS (USA) SENIOR CONSULTANT OPHTHALMOLOGIST ASSOCIATE PROFESSOR FACULTY OF MEDICINE AL NEELAIN UNIVERCITY 1/14/2019 MAHGOUB SALEEM

Neuro-ophthalmology NEURO-OPHTHALMOLOGY 1/14/2019 MAHGOUB SALEEM

4. Lateral Geniculate Bodies 5.Optic radiations 6. Visual cortix Neuro-ophthalmology The Visual Pathway: 1. Optic nerves 2. Optic chiasma 3. Optic tracts 4. Lateral Geniculate Bodies 5.Optic radiations 6. Visual cortix 1/14/2019 MAHGOUB SALEEM

The Visual Pathway: Neuro-ophthalmology Optic nerves = complete blindness 1/14/2019 MAHGOUB SALEEM

The Visual Pathway: Optic chiasma = bitemporal / binasal hemianopia Neuro-ophthalmology The Visual Pathway: Optic chiasma = bitemporal / binasal hemianopia 1/14/2019 MAHGOUB SALEEM

The Visual Pathway: 3. Optic tracts 4. Lateral Geniculate Bodies Neuro-ophthalmology The Visual Pathway: 3. Optic tracts 4. Lateral Geniculate Bodies 5.Optic radiations 6. Visual cortix homonymous hemianopia 1/14/2019 MAHGOUB SALEEM

The Visual Pathway: Neuro-ophthalmology Lesions of Visual Pathways: 1. Trauma 2. Vacular 3. Inflammatory 4. Neoplasms 5. Degenerative 1/14/2019 MAHGOUB SALEEM

The Visual Pathway: Neuro-ophthalmology Pupillary reflexes ` direct ` indirect (consensual) ` near reflex `convergence reflex `accommodation reflex 1/14/2019 MAHGOUB SALEEM

The Visual Pathway: Neuro-ophthalmology Abnormalities of pupillary reactions: 1 . Amaurotic light reflex = No DLR on affected side + No inderect P.reflex on good eye 1/14/2019 MAHGOUB SALEEM

The Visual Pathway: Neuro-ophthalmology Abnormalities of pupillary reactions: 2. Efferent pupillary defect: No DPR+No IPR on affected eye: parasympathetic drugs,atropine, IIInerve palsy,internal ophthalmoloplegia 1/14/2019 MAHGOUB SALEEM

The Visual Pathway: Neuro-ophthalmology Abnormalities of pupillary reactions: 3. Marcus Gunn pupil: 4.Argyil Rebertson pupil (ARP) 5. Adie`s tonic pupil 1/14/2019 MAHGOUB SALEEM

Relative Afferent Papillary Defect Mid-brain pupil Neuro-ophthalmology Horner`s syndrome Relative Afferent Papillary Defect Mid-brain pupil 1/14/2019 MAHGOUB SALEEM

2.Acute Retrobulber nuritis 3.Toxic amblyopia 4.Papilloedema Neuro-ophthalmology Optic nerve diseases: 1.Papillitis 2.Acute Retrobulber nuritis 3.Toxic amblyopia 4.Papilloedema 5.Optic Atrophy(1ry, 2ry) 1/14/2019 MAHGOUB SALEEM

Symptomatic disturbance of vision: Night blindness 2. Day blindness Neuro-ophthalmology Symptomatic disturbance of vision: Night blindness 2. Day blindness 3. Colour blindness 4. Amaurosis 5. Amblyopia 6. Malingering blindness 7. Hysterical blindness 1/14/2019 MAHGOUB SALEEM

Neuro-ophthalmology Neuro-ophthalmology is the subspecialty of both neurology and ophthalmology concerning concerning visual problems that are related to the nervous system 1/14/2019 MAHGOUB SALEEM

Clinical Examination Neuro-ophthalmology Visual Acuity Colour Vision Visual Fields Pupils 1/14/2019 MAHGOUB SALEEM

The swollen optic disc Neuro-ophthalmology Papilloedema Papillitis Malignant hypertension Ischaemic optic neuropathy Diabetic optic neuropathy CRVO Intraocular inflammation 1/14/2019 MAHGOUB SALEEM

Optic neuritis Neuro-ophthalmology 25 y.o. female Reduced VA Pain with eye movement Colour desaturation RAPD Optic neuritis 1/14/2019 MAHGOUB SALEEM

Papilloedema Neuro-ophthalmology • Disc swelling secondary to raised ICP • Headache – Worse in the morning – Valsalva maneuver • Nausea and projectile vomiting • Horizontal diplopia (VI palsy) • Causes – Space occupying lesion – Intracranial hypertension • Idiopathic • Drugs • Endocrine – Severe hypertension 1/14/2019 MAHGOUB SALEEM

The pale optic disc Neuro-ophthalmology Congenital Secondary to • raised ICP • vascular • retinal disease • optic neuritis • optic nerve compression • trauma Glaucoma 1/14/2019 MAHGOUB SALEEM

Pupil Neuro-ophthalmology Reflexes ( direct , consentiual) APD 1/14/2019 MAHGOUB SALEEM

Pupil DM Neuro-ophthalmology Constricted (mioisis) Sympathetic (pupillodilator) denervation Drugs ( Pilocarpine Morphine ) DM 1/14/2019 MAHGOUB SALEEM

DM Pupil Neuro-ophthalmology Dilated (mydriasis) denervation Parasympathetic ( pupilloconstrictor ) denervation Lesion of the III Cranial Nerve Drugs ( Atropine ,Cocaine ) DM 1/14/2019 MAHGOUB SALEEM

Neuro-ophthalmology Sympathetic Pathway READ 1/14/2019 MAHGOUB SALEEM

Horner’s (Oculosympathetic paresis): Neuro-ophthalmology Horner’s (Oculosympathetic paresis): – Ptosis – Miosis – Ipsilateral anhidrosis – Does not dilate with cocaine 4% Causes 1/14/2019 MAHGOUB SALEEM

Afferent & efferent papillary defects APD Neuro-ophthalmology Afferent & efferent papillary defects APD Argyll-Robertson pupil Miotonic pupil (Adie’s syndrome) Holmes-Adie syndrome 1/14/2019 MAHGOUB SALEEM

Cranial Nerve Palsies III IV VI Ophthalmoplegia Neuro-ophthalmology 1/14/2019 MAHGOUB SALEEM

Third nerve palsy Neuro-ophthalmology – Double vision – Eye turned down & out – Ptosis – Dilated pupil & headache • Compressive lesion causes 1/14/2019 MAHGOUB SALEEM

Neuro-ophthalmology IV nerve palsy 1/14/2019 MAHGOUB SALEEM

Sixth nerve palsy Neuro-ophthalmology – Double vision – Eye turned in 1/14/2019 MAHGOUB SALEEM

Internuclear Ophthalmoplegia Neuro-ophthalmology Internuclear Ophthalmoplegia Defective adduction of the ipsilateral eye Nystagmus of the contralateral (abducting) eye NORMAL CONVERGENCE Causes – Young patients • Bilateral • Demyelination – Older patients • Unilateral • Vascular, • tumours 1/14/2019 MAHGOUB SALEEM

• Normal reflexes & sensatio Neuro-ophthalmology Myasthenia Gravis • Fatigability • Double vision • Lid twitch • Ptosis • Normal reflexes & sensatio 1/14/2019 MAHGOUB SALEEM

Neuro-ophthalmology Localising the lesion • Monocular visual field defects indicate lesions anterior to the optic chiasm • Bitemporal defects are the hallmark of chiasmal lesions • Binocular homonymous hemianopia result from lesions in the contralateral postchiasmal region • Binocular quadrantanopias reflect optic tract lesions 1/14/2019 MAHGOUB SALEEM

Neuro-ophthalmology Localising the lesion 1/14/2019 MAHGOUB SALEEM

Neuro-ophthalmology THANK YOU 1/14/2019 MAHGOUB SALEEM