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

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

3. 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

4. Visual light pathway

5. 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

6. Visual field
confrontation

7. Kinetic perimetry Static perimetry

8. SELECT NEURO-OPTH. CONDITIONS

9. 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

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

11. 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

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

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

14. 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

15. 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

16. 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

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

18. 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

19. 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