1. Neuro-ophthalmology Abdulrahman Al-Muammar College of Medicine King Saud University

2. Neuro-ophthalmology Objectives: Recognize and interpret the common signs and symptoms of neuro-ophthalmic disordersRecognize and interpret the common signs and symptoms of neuro-ophthalmic disorders Obtain appropriate history Measure visual acuity Examine pupillary reaction Test the function of the extraocular muscles Evaluate the visual fields Inspect the optic nerve head

3. Neuro-ophthalmology Pupil Ocular motor system Visual system Visual fields Common neuro-ophthalmic disorders

4. Pupil Pupillary size is determined by number of factors including Age Level of alertness Level of retinal illumination Accommodative effort

5. Pupil Anatomy of pupillary pathway Afferent limb Efferent limb Parasympathetic pathwayParasympathetic pathway Sympathetic pathwaySympathetic pathway Near response

6. Pupil

7. Pathway of pupillary reaction to light

8. Sympathetic pathway

9. Afferent pupillary defect (APD)

11. Causes of APD Optic nerve disease Significant retinal disease Amblyopia

12. Efferent pupillary defect

13. Anisocoria

14. Anisocoria

15. Anisocoria Pupillary inequality greatest In bright light (large pupil) In dim light (small pupil) 3 rd nerve palsy Trauma Tumor Temporal lobe herniation Aneurysm No 3 rd nerve palsy Drug induced Adie’s pupil Iris damage (trauma/surgery/laser) Basal meningitis Ptosis Horner syndrome Physiological

16. Anisocoria

17. Horner syndrome

18. Ocular motor system

21. 3 rd nerve palsy + ve pupillary involvement An incomplete III palsy which progress Other neurological signs No resolution in 3 months Aberrant regeneration appears Emergency Do MRI,MRA If negative do catheter angiography To r/o compressive lesion: aneurysm, tumor Other possible causes : vasculopathy, trauma, inflammatory, demyelination, infectious, MG, congenital

22. Ocular motor system

23. 4 th nerve palsy Most frequent cause is trauma Most frequent cause is trauma If no trauma, isolated 4 th nerve palsy then most likely vasculopathic ( Do BP, BS) If no trauma, isolated 4 th nerve palsy then most likely vasculopathic ( Do BP, BS) +ve trauma, any other neurological signs, normal BP/BS or palsy lasting > 3 months then MRI is needed. +ve trauma, any other neurological signs, normal BP/BS or palsy lasting > 3 months then MRI is needed.

24. Ocular motor system

25. 6 th nerve palsy Isolated 6 th nerve palsy most likely vasculopathic ( do BP/BS) Isolated 6 th nerve palsy most likely vasculopathic ( do BP/BS) Normal BP/BS, other neurological signs, trauma, or palsy > 3 months then do MRI Normal BP/BS, other neurological signs, trauma, or palsy > 3 months then do MRI

26. Visual system

29. Visual fields defect

35. Optic disc

37. Disc swelling Mechanical signs Elevation Blurred margins Peripapillary edema Choroid folds Vascular signs Hyperemia Venous dilation Disc hemorrhage NFL infarcts Exudates

38. Causes of disc swelling Increased intracranial pressure Ischemic optic neuropathy Optic neuritis Central retinal vein occlusion Nutritional optic neuropathy Toxic optic neuropathy ETOH-ethanol-Digitalis- ETOH-ethanol-Digitalis- Ethambutol -Chloramphenicol- Ethambutol -Chloramphenicol- INH INHTumorInfiltrative Orbital Pseudotumor Thyroid orbitopathy

41. Amaurosis Fugax Transient monocular visual loss or dimming May last from 2-3 minutes to 30 minutes or more May last from 2-3 minutes to 30 minutes or more Due to decrease blood flow to the eye Causes: Carotid atheromaCarotid atheroma Cardiac valvular diseaseCardiac valvular disease Atrial myxomaAtrial myxoma Retinal migraineRetinal migraine Giant cell arteritisGiant cell arteritis Hyperviscousity syndromesHyperviscousity syndromes

42. Myasthenia Gravis (MG) Chronic auto-immune disorder characterized by presence of antibodies which block the ACH receptor sites It can affect any muscle Eye signs are the presenting signs in 50% of the patients PtosisPtosis Any ocular motility disturbancesAny ocular motility disturbances INOINO Variability is the hallmoarkVariability is the hallmoark

43. Myasthenia Gravis (MG) Diagnosis ClinicallyClinically Pharmacologically (Tensilon test)Pharmacologically (Tensilon test) SerologicallySerologically Sleep testSleep test Ice-pack testIce-pack test CT chestCT chest Thyroid function testThyroid function test ANAANATreatment Acetylcholinesterase inhibitorsAcetylcholinesterase inhibitors SteroidSteroid ImmunosuppressantImmunosuppressant PlasmapheresisPlasmapheresis ThymectomyThymectomy

44. Multiple sclerosis Patients with multiple sclerosis (MS) frequently have visual complaints Cerebellar dysfunction Motor symptoms Sensory symptoms Mental changes Sphincter disturbances

45. Multiple sclerosis Ocular complications: Optic neuritis Chiasmal and retro chiasmal abnormalities Ocular motility disturbances TreatmentSteroidInterferon

46. Thank you