Dr Mahmood Fauzi ASSIST PROF OPHTHALMOLOGY AL MAAREFA COLLEGE Neuro-opHthalmology Dr Mahmood Fauzi ASSIST PROF OPHTHALMOLOGY AL MAAREFA COLLEGE

Objectives Define the term ‘Neuro-Ophthalmology’ Describe the characteristics of normal fundus, optic disc, Identify Selected optic nerve diseases

Neuro-ophthalmology is the sub-specialty of both neurology and ophthalmology concerning visual problems that are related to the nervous system Some commonly seen diseases that a neuro-ophthalmologist may see include optic neuritis, optic neuropathy, papilledema, Optic atrophy

Visual light pathway

Neuro-Ophthalmic Exam Visual acuity Confrontation visual fields Pupil size and reaction Efferent vs Afferent (Marcus Gunn) problem Ocular motility Strabismus, limitation and nystagmus Fundus exam Optic nerve swelling and spontaneous venous pulsations

Visual field confrontation

Kinetic perimetry Static perimetry

SELECT NEURO-OPTH. CONDITIONS

Optic Nerve Disease Non-Arteritic Ischemic Optic Neuropathy (NAION) Vascular disorder Pale, swollen disc +/– splinter hemorrhage Loss of VA , VF ( often altitudinal ) Arteritic Ischemic Optic Neuropathy (AION) Symptoms of giant cell arteritis ESR, CRP, Platelets +/– TABx Rx : systemic steroids

Selected Optic Nerve Diseases Papillitis/Anterior Optic Neuritis Unilateral edema, hemorrhage Consider inflammatory

Optic Nerve Disease Optic neuritis Idiopathic or associated with multiple sclerosis Young adults Decreased visual acuity and colour vision RAPD Pain with ocular movement Bulbar (disc swelling) or retrobulbar (normal disc) Traumatic optic neuropathy Direct trauma to optic nerve Indirect : shearing force to the vascular supply

Selected Optic Nerve Diseases Congenital Anomalous Disc Elevation Absence of edema, hemorrhage Presence of SVP Consider: Optic disc drusen Hyperopia

Selected Optic Nerve Disease Ischemic Optic Neuropathy Pallor, swelling, hemorrhage Altitudinal Visual Field Loss

Sickle Cell Anemia SC and S Thal more likely to have eye involved Arteriolar occlusion intravasc sickling  hemolysis  hemostasis  thrombosis  capillary non-perfusion Similar to diabetes – poor perfusion = retinal ischemia  neovascularization Laser Tx – can prevent vision loss

The swollen optic disc Swelling of optic nerve head other than raised intra cranial pressure Papillitis Malignant hypertension Ischaemic optic neuropathy Diabetic optic neuropathy CRVO Intraocular inflammation

Papilloedema Usually bilateral Disc swelling secondary to raised ICP Absence of SVP Usually bilateral Unilateral papilledema suggest orbital pathology, such as an optic nerve glioma. Headache Worse in the morning Valsalva manouver Nausea and projectile vomiting Horizontal diplopia (VI palsy) Causes Space occupying lesion Intracranial hypertension Idiopathic Drugs Endocrine Diffuse cerebral edema Severe hypertension Obstruction of CSF absorption as in meningitis Blurred optic disc margin Haemorrhages Small optic cup CWS Disc pallor Vessel attenuation

Congenital Anomalous Disc Elevation Absence of edema, hemorrhage Presence of SVP Consider: Optic disc drusen Hyperopia

Papillitis hyperemia of the optic disk and large veins(early signs) edema (nearly more than 3D) (common) blurring of the disk margins (common) filling of the physiologic cup (common) Fundus

Selected Optic Nerve Disease Optic Atrophy: Pallor of optic disc due to damage of retinal ganglion cells. Optic atrophy occurs four to six weeks after cell damage due to reduced blood circulation or inflammation Types: Primary: pallor occurs without prior optic disc swelling, and is due to retro bulbar damage of optic nerve up to lateral geniculate body. Color of Disc is chalky white with well defined margins. Secondary: optic disc swelling is seen prior to pallor, margins may appear less defined, and color appears dirty white to grey. consecutive: consequence of diffuse retinal disease and findings are as in secondary optic atrophy. Consider: Glaucoma Previous optic neuritis Previous ischemic optic neuropathy Long-standing papilledema Optic nerve compression by a mass lesion Retinitis pigmentosa