1. Dr Mahmood Fauzi ASSIST PROF OPHTHALMOLOGY AL MAAREFA COLLEGE

2.  Define the term ‘Neuro-Ophthalmology’  Describe the characteristics of normal fundus, optic disc, visual pathway, papillary reflex  Outline neuro-ophthalmological clinical exams  Recognize and interpret common signs and symptoms of specific Neuro ophthalmologic conditions  Record Abnormal papillary response  Explain Ocular motility abnormalities  Describe Nystagmus (select types)  Identify Selected optic nerve diseases  Explain Visual field defects

3.  Neuro-ophthalmology is the sub-specialty of both Neuro- ophthalmology is the sub-specialty of both neurology and ophthalmology concerning visual problems that are related to the nervous system and ophthalmology concerning visual problems that are related to the nervous system neurology ophthalmologyvisual nervous system ophthalmology visual nervous system  Some commonly seen diseases that a neuro-ophthalmologist may see include optic neuritis, optic neuropathy, papilledema, ocular myasthenia gravis, brain tumors or stroke affecting vision, idiopathic intracranial hypertension, unexplained visual loss, headaches, diplopia, blepharospasm or hemifacial spasm.optic neuritisoptic neuropathypapilledemaocular myasthenia gravisbrain tumorsstroke idiopathic intracranial hypertension headachesdiplopiablepharospasmhemifacial spasm

10.  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

13. confrontation

14. Kinetic perimetry Static perimetry

17. DIRECT CONSENSUAL SWINGING FLASH LIGHT

19.  electrooculogram EOG  electroretinogram ERG  visual evoked potential VEP

21. Papilloedema Papillitis Malignant hypertension Ischaemic optic neuropathy Diabetic optic neuropathy CRVO Intraocular inflammation

22. 25 y.o. female Reduced VA Pain with eye movement Colour desaturation RAPD

23. 65 yrs. male Reduced VA Painless loss of vision Essential hypertension Smoker

24. Congenital Secondary to raised ICP vascular retinal disease optic neuritis optic nerve compression trauma Glaucoma

25.  Disc swelling secondary to raised ICP  Headache  Worse in the morning  Valsalva manouver  Nausea and projectile vomiting  Horizontal diplopia (VI palsy)  Causes  Space occupying lesion  Intracranial hypertension Idiopathic Drugs Endocrine  Severe hypertension Haemorrhages CWS Blurred optic disc margin Small optic cup Disc pallor Vessel attenuation

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

27.  Papilledema  Presence of bilateral edema, hemorrhage  Absence of SVP  Consider Hypertension (must check BP) Brain tumor  Papillitis/Anterior Optic Neuritis  Unilateral edema, hemorrhage  Consider inflammatory

28. Fundus 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)

29.  Optic Atrophy  Consider: Previous optic neuritis Previous ischemic optic neuropathy Long-standing papilledema Optic nerve compression by a mass lesion Glaucoma

30.  Ischemic Optic Neuropathy  Pallor, swelling, hemorrhage  Altitudinal Visual Field Loss

31.  Constricted (mioisis)  Sympathetic (pupillodilator) denervation  Drugs Pilocarpine Morphine  Dilated (mydriasis)  Parasympathetic (pupilloconstrictor) denervation  Lesion of the third CN  Drugs Atropine Cocaine

33.  Mydriasis  CN III palsy Herniation of temporal lobe or Aneurysm  Adie’s Tonic Pupil Young women, Caused by damage to Parasympathetic innervation secondary to bacterial or viral infections. At least one abnormally dilated pupil Diagnoses-vermiform iris movements  Miosis  Physiologic  Horner’s Syndrome o results from an interruption of the sympathetic nerve supply to the eye o Does not dilate with cocaine 4% o (Ptosis+Meiosis+Anhydrosis+Enopthalmos)  Argyll Robertson Pupil o of tertiary syphilis o small, irregular, reacts to near stimulus only Left-sided Horner's syndrome “accommodate but do not react”

34.  An RAPD is a defect in the direct response.  It is due to damage in optic nerve or severe retinal disease. Some causes of a RAPD include:  optic neuritis  ischemic optic disease or retinal disease  severe glaucoma causing trauma to optic nerve  direct optic nerve damage (trauma, radiation, tumor)  retinal detachment  very severe macular degeneration  retinal infection (CMV, herpes) swinging flashlight test

37.  Third nerve palsy  Double vision  Eye turned down & out  Ptosis  Dilated pupil & headache Compressive lesion  Sixth nerve palsy  Double vision  Eye turned in

38.  PCOM Aneurysm  Brain Tumor  Trauma  HTN  Diabetes

39.  Trauma  Elevated ICP  Viral infections

40.  True diplopia is a binocular phenomenon  Etiologies of monocular diplopia?  Do not forget to check ALL cranial nerves (esp V/VII/VIII)  CN IV  Vertical diplopia, head tilt toward OPPOSITE side  Think closed head trauma or small vessel disease

41. Chronic autoimmune condition affecting skeletal muscle neuromuscular transmission (verify with Tensilon test)  Can mimic any nerve palsy and often associated with ptosis  NEVER affects pupil  Fatigability  Double vision  Lid twitch  Ptosis  Normal reflexes & sensation

42.  Defective adduction of the ipsilateral eye  Nystagmus of the contralateral (abducting) eye  NORMAL CONVERGENCE  Causes  Young patients Bilateral Demyelination  Older patients Unilateral Vascular, tumours

43.  May be benign or indicate ocular and/or central nervous system disease  Definition according to fast phase  End-point Nystagmus  Seen only in extreme positions of eye movement  Drug-induced Nystagmus  Anticonvulsants, Barbiturates/Other sedatives  Searching/Pendular Nystagmus  Common with congenital severe visual impairment  Nystagmus associated with INO

45.  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

46.  http://umed.med.utah.edu/neuronet/lectur es/2002/Basics%20in%20Neuro- Ophthalmology.htm http://umed.med.utah.edu/neuronet/lectur es/2002/Basics%20in%20Neuro- Ophthalmology.htm  http://emedicine.medscape.com/article/182 0707-overview http://emedicine.medscape.com/article/182 0707-overview  http://novel.utah.edu/ http://novel.utah.edu/

47.  http://umed.med.utah.edu/neuronet/ex/Ne rvous_Organ_Systems_Test/Neuro- opthamology_Lecture_Quiz/quiz_index.html http://umed.med.utah.edu/neuronet/ex/Ne rvous_Organ_Systems_Test/Neuro- opthamology_Lecture_Quiz/quiz_index.html  http://www.cram.com/flashcards/test/dit- neuro-ophthalmology-2060537 http://www.cram.com/flashcards/test/dit- neuro-ophthalmology-2060537