1. NEURO-OPHTHALMOLOGY

2. Clinical Examination
Visual Acuity
Colour Vision
Visual Fields
Pupils

3. Normal Eye and Optic Disc
Cupped disc

4. The swollen optic disc Papilloedema Papillitis Malignant hypertension
Ischaemic optic neuropathy
Diabetic optic neuropathy
CRVO
Intraocular inflammation

5. 25 y.o. female
Reduced VA
Pain with eye movement
Colour desaturation
RAPD

6. 65 y.o. male
Reduced VA
Painless loss of vision
Essential hypertension
Smoker

7. The pale optic disc Congenital Secondary to raised ICP
vascular retinal disease
optic neuritis
optic nerve compression
trauma
Glaucoma

8. Papilloedema Disc swelling secondary to raised ICP Headache
Blurred optic disc margin
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
Small optic cup
CWS
Disc pallor
Vessel attenuation

9. Pupils First Order – Retina to Pretectal Nucleus in B/S
(at level of Superior colliculus)
Second Order – Pretectal nucleus to E/W nucleus
(bilateral innervation!)
Third Order – E/W nucleus to Ciliary Ganglion
Fourth Order – Ciliary Ganglion to Sphincter
pupillae (via short ciliary nerves)

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

12. Horner’s Oculosympathetic paresis Ptosis Miosis Ipsilateral anhidrosis
Does not dilate with cocaine 4%

13. Sympathetic Pathway First Order – Posterior Hypothalamus to
Ciliospinal centre of Budge (C8-T2)
(Uncrossed in Brainstem)
Second Order – Ciliospinal centre of Budge to
Superior Cervical Ganaglion
Third Order – Superior Cervical Ganglion to
dilator pupillae muscle. (Close to
ICA and joins V1 intracranially)

14. CVA Tumour Internal Carotid Dissection Herpes Zoster Otitis Media
Tolosa-Hunt Sy.
Pancoast bronchogenic carcinoma

15. Causes of Horner’s pupil
Central – B/S lesions (tumours, vascular and MS)
Syringomyelia, Lat. Med. Syn., S.C. ca.
Preganglionic – Pancoast tumour, Carotid & Aortic
aneurysms, Neck lesions/trauma.
Postganglionic – Cluster headaches, Nasopharyngeal
tumours, Otitis media, Cavernous
sinus mass and ICA disease.
Miscellaneous – Congenital (brachial plexus injury)
Idiopathic.

16. Afferent & efferent defects
Argyll-Robertson pupil
Small, irreg
Does not react to light
Reacts to accommodation
Causes
syphilis
diabetes
Miotonic pupil (Adie’s syndrome)
Dilated
Poor response to light and convergence.
Constricts with weak Pilocarpine
Holmes-Adie syndrome
Reduced tendon reflexes (Knee, ankle)
- Orthostatic hypotension

17. Ocular motility abnormalities
Third nerve palsy
Double vision
Eye turned down & out
Ptosis
Dilated pupil & headache
Compressive lesion
Sixth nerve palsy
Double vision
Eye turned in

18. Cranial Nerve Palsies
Looking straight ahead

19. Posterior communicating artery aneurysm
Chiasma
Posterior cerebral artery
III CN

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

21. Myasthenia Gravis Fatigability Double vision Lid twitch Ptosis
Normal reflexes & sensation

22. INVESTIGATIONS MG Anti ACh receptor Ab’s Electromyography
Tensilon test
Edrophonium blocks acetyl-cholinesterase
Beware of cholinergic cardiac effects. Use with Atropine 0.6mg
Thoracic CT and MRI to rule out thymoma
ACh
Anti AChR Ab’s
AChR

24. Localising the lesion
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