Neur Ophthalmic Eye Disease

Front 1

Anisocoria

Back 1

-pupils of unequal size
-difference of 0.75 and 1.0 mm is significant
-physiologic will show the same difference in pupil size in dark and bright

Front 2

Anisocoria greater in bright

Back 2

problem with iris constrictor -> sign of parasympathetic involvement -> larger pupil is abnormal

Front 3

Anisocoria greater in dim

Back 3

problem with dilator -> sign of sympathetic involvement -> smaller pupil is abnormal

Front 4

Tonic Pupil Syndrome

Back 4

-anicoria in which one eye is larger in bright light and the other eye is larger in dim light
-parasympathetic and sympathetic involvement

Front 5

1/8% pilocarpine

Back 5

-tests to see if pupils are pharmacologically dilated
-for normal px (and those that are pharmacologically fixed), pilo should NOT elicit pupillary response
-px with prior presynaptic nerve damage will have an increased sensitivity to ACH (up-regulation) and pupil will constrict after 30 minutes

Front 6

Should you do the pilocarpine test on pxs you suspect a 3rd nerve palsy?

Back 6

NO

Front 7

5 causes of Light-Near Dissociation

Back 7

1. Argyll-Roberts (syphilis)
2. Dorsal Midbrain Syndrome
3. Amaurotic eye
4. Tonic pupils
5. Aberrent regeneration

Front 8

Differential Diagnoses of tonic pupil

Back 8

-posterior synechia
-acute angle closure glaucoma
-bitemporal sphincter palsy/temporal iris ischemia
-tadpole pupils

Front 9

Pupil appearance of a tonic pupil

Back 9

-mid-dilated
-tonic pupil is larger in bright light
-tonic pupil is smaller in dim light
-tonic pupil is light-near dissociated (pupil constricts to accommodation but not to light)

Front 10

What does bitemporal sphincter palsy look like and what is it caused by?

Back 10

-vertically oriented pupils
-caused by ischemic ocular syndrome (esp in diabetics) or from ischemia secondary to PRP in diabetics

Front 11

What are tadpole pupils associated with?

Back 11

-migraines and sympathetic irritation
-unusual dilation during a headache
-benign condition

Front 12

3 cardinal signs of a tonic pupil

Back 12

1. Sector paralysis
2. Stromal spread
3. Stromal streaming

Front 13

Sector paralysis

Back 13

-tonic pupil has curved and flattened parts
-flat region is sectors of iris that are paralyzed
-there is loss of tone due to lesion of short posterior ciliary nerves

Front 14

Stromal Spread

Back 14

-iris has radial folds bt iris sphincter and dilator muscles
-loss of tone causes stroma to disorganize and surface of iris becomes lax

Front 15

Stromal Streaming

Back 15

-damaged iris will stream towards light beam of slit lamp
-when light is on the iris, normal part streams to tighten, but the damaged part does not move at all; may appear to rotate orr go to one side as it constricts

Front 16

What is the cause of tonic pupils?

Back 16

-ciliary ganglion is damaged

Front 17

Edinger Westphal nucleus

Back 17

-explains light-near dissociation
-3% of fibers from EW go to sphincter muscle for constriction; 90% of fibers from EW are for accommodative function
-Ciliary ganglion gives rise to most of fibers for constriction
-therefore damage to CG and not EW will affect a small portion of accommodative fibers and many more constrictive fibers
-thus, near accommodative ability is left intact

Front 18

Causes of Tonic Pupils

Back 18

1. Local tonic pupil caused by infection in the orbit (varicella, retrobulbar masses, PRP, orbital tumor)
2. Neuropathic causes (diabetes is most common cause*, syphilis, sarcoidosis, lyme disease)
3. Idiopathic causes = Adie's tonic pupil

Front 19

What do you have to rule out before you can call a tonic pupil Adie's?

Back 19

DM, syphilis, sarcoidosis, Lyme's

Front 20

Adie's Tonic pupil characteristics

Back 20

-browache, anisocoria, trouble focusing
-female prevalence
-age 20-40
-**90% unilateral presentation
-fellow eye involvement is common at 4% per yr

Front 21

What is Adie's Tonic Pupil accompanied by?

Back 21

-diminished corneal sensitivity
-decreased deep tendon reflexes

Front 22

Management of Adie's Tonic Pupil

Back 22

-leave it alone
-if px is experiencing symptoms: homatropine OU to alight near pt and prescribe reading glasses (may need unequal add)
-glasses
-occlusion
-colored contacts

Front 23

CN III Palsy features

Back 23

-ptosis
-mid-dilated pupil
***involved pupil = aneurysm
***spared pupil = vasculopathic (DM)
-reduced response to light and near
-external ophthalmoplegia
-complete and incomplete inability to move eye in or up
-pain

Front 24

Complete or Incomplete CN III palsy

Back 24

1. Complete & dilated pupil = aneurysm
2. Complete & spared pupil = diabetes
3. Incomplete & dilated pupil = aneurysm
4. Incomplete and spared pupil = CAN'T TELL

Front 25

Acute onset CN III palsy with pupil involvement

Back 25

= aneurysm at junction of posterior communicating and internal carotid arteries = EMERGENCY (20f% die within 48 hrs)

Front 26

Dorsal Midbrain Syndrome

Back 26

= Parinaud's Syndome = Sylvian Aqueduct Syndrome
-compression from back of midbrain from tumor, CSF obstruction, inflammatory, infection

Front 27

DMS Signs

Back 27

-tectal pupils (mid-dilated & dont react well to light but fine for near)
-upgaze paresis
-convergence-retraction nystagmus (bc px cant look up so eyes go in or out)
-eyelid retraction (Collier's sign); eyes cant look up but eyelids can still rise normally

Front 28

Possible cause of DMS

Back 28

-pineal gland tumor (just posterior to dorsal midbrain)
-pineal tumor looks like bone on MRI and CT due to calcification

Front 29

Uncal Syndome

Back 29

-severe lid retraction
-unable to look up
-light near dissociation
-uncal hernation due to sudden increased ICP shifting cerebral contents
-compression of uncus of temporal lobe compressing the third nerve causes the pupil to become fixed and dilated
-Blown pupil = *Hutchinson Pupil

Front 30

Horner's dilation lag

Back 30

anisocoria is greater at 5 seconds than at 12 seconds into darkness; in a normal physiologic/benign essential anisocoria, the pupil is fully dilated at 5 seconds so there is no difference in relative pupil size at 5 seconds and at 12 seconds

Front 31

Horner's cocaine test

Back 31

-positive test results in no dilation
-cocaine blocks the reuptake of norepinephrine at the nerve terminal
-normal pxs have a normal amount of norepinephrine, and the blockage by cocaine causes dilation
-horner's pxs have a decreased amount of norepinephrine, and the blockage by cocaine does not do anything; thus the patient does not dilate

Front 32

Apraclonidine test for Horner's

Back 32

-potential new diagnostic test
-no effect on normal pupil
-dilates Horners pupil bc it is supersensitive
-OPPOSITE of cocaine test
-look for reversal of anisocoria

Front 33

Eyelid crease in Horner's vs Myasthenia Gravis

Back 33

-Horners: eyelid crease is still present bc levator function is normal
-Myasthenia Gravis: CN III disease that causes disinsertion of the tarsal plate; eyelid crease absent bc the levator is affected

Front 34

Inverse Ptosis

Back 34

-in Horners, lower lid looks elevated due to inability of inferior muscle of Mueller to pull lower lid down
-presence indicated Horners
-Myasthenia Gravis & CN III palsy do NOT have inverse ptosis

Front 35

Heterochromia iridis

Back 35

-stromal melanocytes in iris need sympathetic innervation to mature and give iris its color
-look for lighter iris on side you suspect Horner's
-generally occurs only in congenital Horner's (before age 2)

Front 36

Ipsilateral straightening of hair

Back 36

-sympathetic nerve fibers innervate the scalp
-before age 2, for px to have curly hair there must be sympathetic activity in the scalp
-horner's px may have curly hair on one side and straight on the other due to lack of sympathetic innervation
-generally in congenital Horner's

Front 37

What are two signs of congenital Horner's?

Back 37

-heterochromia iridis
-ipsilateral straightening of hair

Front 38

What is the most common cause of Horner's in young patients?

Back 38

Neuroblastoma
-causes Klumpke's sign (lack of sympathetic innervation to arms and hands; no wrinkling in water) and Gustatory lid retraction (certain neural stimuli such as eating a lemon causes the lid to shoot up and the pupil to dilate)

Front 39

CN IV palsy & Horner's

Back 39

-oculosympathetic fibers travel from midbrain to pons at locus ceruleus
-locus ceruleus is ver close to CN IV
-CN IV crosses in midbrain and when lesioned can cause a contralateral Horner's

Front 40

Foville Syndome & Horner's

Back 40

-level of pons
-fibers from midbrain travel to caudal pons
-lesion here such as infarct of anterior inferior cerebellar artery can cause Foville syndrome
-infarct of AICA
-CN VI damage
-CN VII palsy (CN VI and VII are next to each other in pons)
-CN VIII palsy
-CN V palsy

Front 41

Wallenberg Syndrome & Horner's

Back 41

-oculosympathetic fibers travel from pons to lateral medulla
-infarct here causes Wallenberg Syndrome
-occurs with Horner's intermittent diplopia, contralateral loss of pain and temp, ipsilateral loss of hearing, swallowing and speech difficulties, nystagmus, nausea, ipsilateral ataxia

Front 42

Phrenic nerve or brachial plexus Syndrome

Back 42

-at the level of the spinal cord
-mostly associated with female pxs
-associated with metastatic breast cancer
-Triad of phrenic nerve syndrome : hoarse, hiccoughs, and Horner's

Front 43

What kind of lung tumor is associated with Horner's?

Back 43

Pancoast's tumor
-fibers at the level of c7-T2 split and travel very close to the apex of lung
-Triad of pancoast tumor: ptosis, miosis, arm pain

Front 44

Carotid Artery dissection

Back 44

-px may present with Horner's bc sympathetics travel around carotid plexus
-may also have amauosis fugax, dysgeusia (metallic taste), eye pain
-EMERGENCY
-can lead to stroke, esp in young pxs
-50-95% will have retinal or cerebral ischemia if left untreated
**Triad of Carotid Dissection:
1) pain on side of face, head, or neck
2) oculosympathetic paralysis without anhydrosis
3) delayed retinal or cerebral ischemia

Front 45

A tumor at the base of the skull that can produce a Horner's is called what?

Back 45

Vernet's Syndrome
-nasopharyngeal cancer
-px presents with droopy shoulder
-droopy tongue
-winged scapula
-weak trapezius
-hoarse
-tongue deviated to one side

Front 46

1st, 2nd, and 3rd order neurons

Back 46

1st- brain to clavicle
2nd- clavicle to mandible
3rd- mandible to eye

Front 47

Paredrine 1% Test

Back 47

-located Horner's lesion if it is isolated
-paredrine puts norepinephrine from the presynaptic nerve terminal into the synapse
-if lesion occurs at 3rd order neuron (postganglionic), above the mandible, the pupil will NOT dilate unless the lesion is acute and there has been time to deplete the neurotransmitter
-if the lesions is at the 1st or 2nd order neuron (preganglionic), below the mandible, then the pupil WILL dilate

Front 48

Causes of Horner's?

Back 48

1. 40% idiopathic
2. 13% malignant tumor, usually Pancoast
3. Neuroblastoma in children

Front 49

Rule of thumb localization

Back 49

1st neuron lesion, think vascular disease or trauma
2nd neuron lesion, think neoplasia
3rd neuron lesion, think benign or headache syndrome

Front 50

Argyll-Robertson pupils

Back 50

-miosis, 2.5 mm max in dark
-absent direct response to light
-light near dissociation (normal response to near)
-preserved vision
-unilateral, asymmetric, or unequal
-dilates poorly