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CLINICAL VIGNETTE
2019; 5:1
NEURO-OPHTHALMIC ASSESSMENT
DR. B. C. UGWU
Editor-in-Chief: Prof Olufemi Idowu Neurological surgery Division, Department of Surgery, LASUCOM/LASUTH, Ikeja, Lagos, Nigeria.
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2. NEURO-OPHTHALMIC ASSESSMENT
DR. B. C. UGWU
Eye Foundation Hospital ,
GRA, Ikeja, Lagos
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OUTLINE
Introduction
History
Examination
i) General and systemic
ii) Ocular
Investigations
i) visual fields
ii)neuroimaging
iii) B-scan
iv)visual evoked potential
v) optical coherence tomography
vi) other investigations
References
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INTRODUCTION
Neuro-ophthalmological assessment involves history, examination and investigations aimed at diagnosing a neuro-ophthalmic pathology
Not to be seen as an independent process, but complementary to full neurological assessment
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HISTORY
Blurry vision, Transient obscuration or loss of vision, Diplopia, Ptosis, Scotomas, Proptosis
Ocular pain especially on eye movement
Nystagmus, Ocular deviation
Amenorrhoea or oligo-menorrhoea, galactorrhoea, severe post partum haemorrhage, Gynaecomastia,
Headaches, vomiting, head trauma
Systemic diseases-Hypertension, Diabetes mellitus, Systemic lupus erythematosus, Rheumatoid arthritis, multiple sclerosis
Drug history-Ethambutol
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GENERAL EXAMINATION
Head posture- head tilt, chin lift,
Thickened superficial temporal artery
Pallor
Thyroid mass
Features of acromegaly- acral and tongue enlargement
SYSTEMIC EXAMINATION
NEUROLOGICAL EXAMINATIONS
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OPTIC NERVE
Visual acuity- Snellen chart (at 6 m); Jaeger or Rosenbaum chart (hand- held card, at 30 cm); +/- pin hole test (tiny 2 mm perforation- improve vision indicates refractory error); Count fingers; Hand movement; Light perception
Pupils- swinging flashlight test- Marcus Gunn pupil- relative afferent pupillary defect; Multiple sclerosis, Diabetes mellitus (DM)
@MIOSIS- Horner’s syndrome- (miosis, enophthalmos, partial ptosis, anhidrosis); Argyll Robertson- unreactive irregular small pupil, normal accommodation in tertiary syphilis, DM; Pontine injury
@MYDRIASIS- Holmes-Adie syndrome- unilateral dilated pupil, slow light reflex, normal accommodation, absent knee jerks (benign); DM; Temporal lobe herniation
Visual Field- Confrontational vs automated; central, peripheral
Fundoscopy- Disc and retina
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FUNDUSCOPY
Size, cup disc ratio, colour, oedema, congenital abnormalities,
Flat/elevated/ tilted,
Haemorrhages, retinociliary collateral vessels,
Papilledema is bilateral disc oedema caused by raised ICP
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OCULAR EXAMINATION
Lids and orbit-ptosis, proptosis
Ocular alignment-exotropia or exotropia, hypertropia or hypotropia
Extraocular muscles;
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10. OCULOMOTOR NERVE PALSY
Diplopia-worse on contralateral gaze
Ptosis, Limited elevation and adduction so that the eye is turned out and down due to unopposed actions of Superior Oblique & Lateral Rectus
CN III Palsy-pupil affected or pupil sparing(medical vs surgical)
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SIGNS OF CN IV PALSY
Hypertropia of the affected side, "worse on opposite gaze"- WOOG
Limitation of depression most marked on abduction
Extorsion to the ipsilateral side
Diplopia –vertical or torsional, worse on downward gaze
Contralateral Head tilt to compensate for lack of intorsion
Exclude bilateral invovlment- crossed hypertropia, excyclotorsion of 10 degrees or more, and a large V-pattern of strabismus
Deviation is "better on opposite tilt"– BOOT
SIGNS OF CN VI PALSY
Esotropia
Horizontal diplopia
Abduction deficit
Compensatory head turn to the side of the lesion
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12. INVESTIGATIONS- VISUAL FIELDS
Practically all VF info lies in central 30 degrees
Covers 66% of the ganglion cells
Corresponds to 83% of the visual cortex
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RELIABILITY INDICES
10% of the stimuli are used at random to test the patient’s cooperation
False Positive errors>20%- unreliable
False Negative errors>20%- unreliable
Fixation losses >33%- unreliable
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16. RADIOLOGICAL INVESTIGATIONS
Computer Tomography Scan
Magnetic resonance imaging-
Measure optic nerve sheath diameter in papilledema ( mm)
Idiopathic intracranial Hypertension slit-like ventricles & flattening of the pituitary gland (‘empty sella’ sign) are found
B-Scan- to measure optic nerve sheath diameter in papilledema, measured at 3mm behind the optic nerve head, values > 5mm is high
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17. VISUAL EVOKED POTENTIAL (VEP)
Measures the electrical signal generated at visual cortex in response to visual stimulation
Depends on the integrity of the visual pathway
Stimulus- flash of light (flash VEP) or a black-and-white checkerboard pattern on a screen (pattern VEP)
Latency (delay) and amplitude are assessed
It contains a prominent positive component – P100 and 2 negative components – P70 and P135
Can be used as a rough measure of VA in children & uncooperative patients
VEP Parameters altered in
Optic neuritis
Ischemic optic neuropathies
Multiple sclerosis
Cortical blindness
Compressive optic lesions
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OPTICAL COHERENCE TOMOGRAPHY (OCT)
Non invasive imaging that utilizes the principle of Michelson interferometry
Can quantify nerve fibre layer and ganglion cell losses
Measurements of Retina Nerve Fibre Layer (RNFL) thickness are shown in Temporal, Superior, Nasal, Inferior, Temporal (TSNIT) orientation and are compared to age matched normal
Green area- 5th-95th percentile by age, yellow area is 1st -5th percentile and red area is below the 1st percentile
RNFL thickness map/ optic nerve head map should have a bow tie pattern
Indications-optic atrophy/neuropathy, optic disc oedema
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OTHER INVESTIGATIONS
Blood sugar levels : To rule out diabetic papillopathy
Serum Lipid profile and Serum Homocysteine levels-Non- Arteritic Anterior Ischaemic Optic neuropathy (N-AION)
ESR and CRP : Marker of inflammation : (Arteritic-AION)
Temporal artery biopsy : Giant cell arteritis (A-AION)
Cerebrospinal fluid examination : CSF Opening pressure increased in Idiopathic intracranial hypertension, microscopic examination in Multiple sclerosis
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REFERENCES
Kanski clinical ophthalmology -8th Ed
Miller NR, Newman NJ, Biousse V, Kerrison JB. Walsh and Hoyt’s clinical neuro ophthalmology. 6th ed. 2005, Lippincott Williams & Wilkins.
Walsh TJ. Neuro ophthalmology – clinical signs and symtopms. 4thed Mosby, Williams & Wilkins.
Schiefer U, Wilhelm H, Hart WM. Clinical Neuro ophthalmology, a practical guide. 2007, Springe
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