Dr Mahmood Fauzi
ASSIST PROF OPHTHALMOLOGY
AL MAAREFA COLLEGE
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


Neuro-ophthalmology is the sub-specialty of both Neuroophthalmology 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

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.
 Visual
acuity
 Confrontation visual fields
 Pupil size and reaction

Efferent vs Afferent (Marcus Gunn) problem
 Ocular

Strabismus, limitation and nystagmus
 Fundus

motility
exam
Optic nerve swelling and spontaneous venous pulsations
confrontation
Kinetic perimetry Static perimetry
DIRECT
CONSENSUAL
SWINGING FLASH LIGHT
 electrooculogram
EOG
 electroretinogram
ERG
 visual evoked potential VEP
•Papilloedema
•Papillitis
•Malignant hypertension
•Ischaemic optic neuropathy
•Diabetic optic neuropathy
•CRVO
•Intraocular inflammation
25 y.o. female
Reduced VA
Pain with eye movement
Colour desaturation
RAPD
65 yrs. male
Reduced VA
Painless loss of vision
Essential hypertension
Smoker
•Congenital
•Secondary to
•raised ICP
•vascular retinal disease
•optic neuritis
•optic nerve compression
•trauma
•Glaucoma

Disc swelling secondary to raised ICP

Headache
 Worse in the morning
 Valsalva manouver
Haemorrhages
Nausea and projectile vomiting
Horizontal diplopia (VI palsy)
Causes
 Space occupying lesion
 Intracranial hypertension
 Idiopathic
Disc pallor
 Drugs
 Endocrine
 Severe hypertension



Vessel attenuation
Blurred optic
disc margin
CWS
Small optic
cup
 Congenital
Anomalous Disc Elevation

Absence of edema, hemorrhage
Presence of SVP

Consider:



Optic disc drusen
Hyperopia
 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
•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
 Optic

Atrophy
Consider:





Previous optic neuritis
Previous ischemic optic neuropathy
Long-standing papilledema
Optic nerve compression by a mass lesion
Glaucoma
 Ischemic


Optic Neuropathy
Pallor, swelling, hemorrhage
Altitudinal Visual Field Loss
 Constricted
(mioisis)
 Sympathetic
(pupillodilator)
denervation
 Drugs
 Pilocarpine
 Morphine
 Dilated
(mydriasis)
 Parasympathetic
(pupilloconstrictor)
denervation
 Lesion of the third
CN
 Drugs
 Atropine
 Cocaine

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
Left-sided Horner's syndrome
results from an interruption of the
sympathetic nerve supply to the eye
o Does not dilate with cocaine 4%
o (Ptosis+Meiosis+Anhydrosis+Enopthalmos)
o

o
o
Argyll Robertson Pupil
of tertiary syphilis
small, irregular, reacts to near stimulus
only
“accommodate but do not react”
swinging flashlight test


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)
 Third




nerve palsy
Double vision
Eye turned down &
out
Ptosis
Dilated pupil &
headache

Compressive lesion
 Sixth


nerve palsy
Double vision
Eye turned in
 PCOM
Aneurysm
 Brain Tumor
 Trauma
 HTN
 Diabetes
 Trauma
 Elevated
ICP
 Viral infections

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

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
•
Defective adduction
of the ipsilateral eye
 Nystagmus of the
contralateral
(abducting) eye
 NORMAL
CONVERGENCE
 Causes
 Young patients
 Bilateral
 Demyelination
 Older patients
 Unilateral
 Vascular, tumours

 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
 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
 http://umed.med.utah.edu/neuronet/lectur
es/2002/Basics%20in%20NeuroOphthalmology.htm
 http://emedicine.medscape.com/article/182
0707-overview
 http://novel.utah.edu/
 http://umed.med.utah.edu/neuronet/ex/Ne
rvous_Organ_Systems_Test/Neuroopthamology_Lecture_Quiz/quiz_index.html
 http://www.cram.com/flashcards/test/dit-
neuro-ophthalmology-2060537