Ocular Abnormality- Neuro-Ophthalmology

Front 1

How would you evaluate optic nerve function?

Back 1

By:

• Appearance

• Visual fields

• Pupil reactions

• Colour vision

• Visual acuity

• Diminished Light brightness sensitivity

• Diminished contrast sensitivity

Front 2

What should you note about the physical appearance of the optic nerve head?

Back 2

– Colour

– Shape

– Size

– Margins

– Elevation

– Additional features

• Haemorrhages

• Vascular changes

Front 3

How would you evaluate the function of the optic nerve- visual fields?

Back 3

Measured with full threshold automated perimetry

–Humphrey 30-2

Front 4

What kind of field defect is this?

Back 4

Centrocaecal

– Central scotoma with enlarged blind spot

Front 5

What kind of field defect is this?

Back 5

– Altitudinal

• Obeys horizontal mid-line affecting either inferior or superior field

Front 6

What would the swinging light test tell a out the optic nerve function?

Back 6

• Lesions of optic nerve head

• Gross retinal lesions

• Relative afferent pupil defect

• Pupil reacts slower relative to the other

• If vision loss absolute -afferent pupillary defect present

– Affected eye, when light shone in pupil will not constrict at all

Front 7

Name some acquired anomalies of the optic nerve.

Back 7

• Optic neuritis

– Papillitis

– Neouroretinitis

– Retrobulbar neuritis

• Anterior ischaemic optic neuritis

• Optic atrophy

• Papilloedema

Front 8

What is Optic neuritis - Papillitis?

Back 8

• Inflammation of the optic nerve head

Front 9

What would be seen with Optic neuritis - Papillitis?

Back 9

• Discs welling visible on ophthalmoscopy

• Variable disc hyperamia and oedema

• Cells in posterior vitreous

Front 10

In who is Optic neuritis - Papillitis more common in?

Back 10

Children- post viral

Front 11

What is Optic neuritis- Neouroretinitis?

Back 11

Papillits with inflammation of retinal nerve fibre layer

Least common

Usually self limitng

Front 12

What would be seen with Optic neuritis- Neouroretinitis?

Back 12

Macula star

– Exudates

Front 13

What is Retrobulbar neuritis associated with?

Back 13

Usually with demyelinating diease MS

Front 14

What does Demyelinating Optic Neuritis present with?

Back 14

• Reduced VA

• Reduced VF

• Colour vision defects

• RAPD

• Pain on eye movements

Front 15

What is Optic neuritis by aetiology?

Back 15

• Demyelination

• Parainfectious

– Viral infection, immunization

• Infectious

– Cat scratch fever, syphilis, AIDS, herpes zoster, meningitis

• Non-infectious

Front 16

What is demeylination?

Back 16

• Destruction of insulating sheath on nerves

• Disrupts conduction in nerves

Front 17

What is the commonest cause for demeylination?

Back 17

Multiple Sclerosis

Front 18

What is Multiple Sclerosis?

Back 18

– Idiopathic demyelinating disease

– More common in women

– Onset third to fourth decades

– Relapsing remitting disease

Front 19

What are the ocular features Multiple Sclerosis?

Back 19

• Optic neuritis (retrobulbar) Internulear ophthalmoplegia

• nystagmus

Front 20

What are the symptoms of demyelinating optic neuritis?

Back 20

• Sub-acute unilateral visual loss

• Rarely bilateral

• Discomfort on eye movements~90%

• Tiny flashes of light?

• Frontal headache, tenderness of the globe(rare)

Front 21

What will the visions be like with demyelinating optic neuritis?

Back 21

Reduced visual acuity

• V/A 6/18 to 6/60 rarely worse

• RAPD

• Colour desaturation

Front 22

What would the disc look like with demyelinating optic neuritis?

Back 22

• Normal optic nerve head occasionally papillitis

• Possible temporal disc pallor

Front 23

What would the visual fields look like with demyelinating optic neuritis?

Back 23

– Reduction in sensitivity

– Altitudinal defects

– Arcuate

– Or central/ centrocoaecal

Front 24

What is the optometric management for demyelinating optic neuritis?

Back 24

Refer urgently to neurologist (VF plots)

Front 25

What is the treatment for demyelinating optic neuritis?

Back 25

• Intravenous steroids

• Immunodulatory treatment

Front 26

What is Anterior ischaemic optic neuritis AION?

Back 26

• Partial or total infarction of optic nerve head

• Occlusion of short posterior ciliary arteries

Front 27

What are the 2 types of Anterior ischaemic optic neuritis?

Back 27

• Non-artertic

• Arteritic

Front 28

Which type of Anterior ischaemic optic neuritis is more common?

Back 28

Non-artertic

Front 29

What are the predisposing factors to non-artertic AION?

Back 29

– Structural crowding of optic nerve head

– Hypertension

– Diabetes mellitus

– Age> 50 years of age

Front 30

What are the symptoms of non-artertic AION?

Back 30

Sudden loss of vision often on waking

Front 31

What are the signs of non-artertic AION?

Back 31

• VA normal or slightly reduced

• VF defect– typically inferior altitudinal, central, paracental or arcuate defects

• Colour vision affected

• Diffuse or sectoral hyperaemic disc swelling

• Few splinter haemorrhages

Front 32

What is the management for non-artertic AION?

Back 32

• Emergency referral to neurologist

• Full vascular work up

Front 33

What is the treatment for non-artertic AION?

Back 33

• No definitive treatment

• Treat any underling cause

• Aspirin

Front 34

What is the prognosis of non-artertic AION?

Back 34

50% achieve 6/9

25% 6/60 or worse

reoccurs- affects the other eye

Front 35

What is arteritic AION?

Back 35

Giant cell arteritis

Front 36

What are the symptoms of Giant cell arteritis?

Back 36

• Thickened tender superficial temporal arteries

• Scalp tenderness –night and cold

• Headache

– normally constant

• Local or generalised

• Jaw .claudication

Front 37

What are the ocular symptoms of Giant cell arteritis?

Back 37

– Sudden profound loss of vision

• May be preceded by amaurosis fugax

– Unilateral

– Periocular pain

Front 38

What are the signs of arteritic AION?

Back 38

• Severe visual loss

• Pale chalky white disc

• Occasionally may be bilateral

• Splinter haemorrhages

• Over 1-2 months swelling resolves

• Optic atrophy

• Prognosis very poor

Front 39

What is the management for arteritic AION?

Back 39

Refer as an emergency

Front 40

What is Optic atrophy?

Back 40

• Late stage changes in optic nerve

• Axonal degeneration between retina and LGN

Front 41

State the different types of optic atrophy.

Back 41

• Primary

– Not associated with another disease

• Secondary – Associated with another disease

• Consecutive optic atrophy

– Disease of the inner retina or blood supply

• Glaucomatous optic atrophy

Front 42

What are the signs of Primary Optic Atrophy?

Back 42

• Flat white disc

• Margins clearly defined

• Reduction innumber of bloodvessels on disc surface

• Attenuation of peripapillary bloodvessels

• Thinning of nerve fibre layer

Front 43

What are the causes of Primary Optic Atrophy?

Back 43

• Optic neuritis

• Compression by tumours and aneurysms

• Hereditary optic neuropathies

• Toxic and nutritional

• Trauma

Front 44

What are the ocular effects of optic atrophy?

Back 44

• Visual acuity is reduced, effects mild to severe

• Visual fields are affected

• Colour vision may be affected

• May be associated with nystagmus

Front 45

What is Secondary Optic Atrophy?

Back 45

Preceded by long-standing swelling of the optic nerve

Front 46

What would be seen with Secondary Optic Atrophy?

Back 46

• Slightly raised greyish disc

• Poorly defined margins – proliferation of glial cells

• Reduction of number of blood vessels on disc surface

• Retinochoroidal folds

Front 47

What are the causes of Secondary Optic Atrophy?

Back 47

– Chronic papilloedema

– AION

– Papillitis

Front 48

What is Consecutive Optic Atrophy?

Back 48

• Extensive retinal photocoagulatuion

• Central retinal artery occulsion

Front 49

What would be at the disc with Consecutive Optic Atrophy?

Back 49

Waxy with well preserved blood vessels

Front 50

What is Papilloedema?

Back 50

Bilateral but often asymmetrical disc swelling due to raised intracranial pressure

Front 51

What are some of the other causes of papilloedema?

Back 51

– Idiopathic intracranial hypertension

– Intracranial haemorrhage

– Trauma

Front 52

What are the symptoms of Papilloedema?

Back 52

• Headache characteristics– worse after exercise, bending, head movement or coughing

– may waken patient from sleep

• Nausea, projectile vomiting

• Deterioration of consciousness

Front 53

What would be seen in early Papilloedema?

Back 53

• Visual acuity normal

• Dilated nerve fibres

• Venous engorgement

• Mild disc swelling and hyperaemia

• Blurring of disc margins and peripaillary retinal nerve fibre layer

• Loss of spontaneous venous pulsation

Front 54

What would be seen with established Papillioedema?

Back 54

• Normal or reduced VA

• Visual obscurations

• Increased hyperaemia

• Disc swelling no physiological cup

• Venous engorgement

• Cotton wool spots

• Retinal folds

• Hard exudates

Front 55

How would you manage Papillioedema?

Back 55

Refer as an emergency

Front 56

What percentage of the population have perceptible Anisocoaria?

Back 56

20%

Asymmetry up to 2mm

Front 57

When is abnormally large pupils lesa noticeable?

Back 57

Under low lighting conditions

Front 58

What are the ocular effects of Adie's Pupil?

Back 58

Dilated pupil with weak or absent response to light

• Most have accommodative involvement initially

• Light near dissociation

• Risk of amblyopia

Front 59

When is abnormally small pupils lesa noticeable?

Back 59

Under low lighting conditions as the normal pupil dilates

Front 60

What are the ocular signs of Horner's syndrome?

Back 60

• Usually unilateral

• Ptosis <2mm & lower lid elevation

• Miosis

• Anhidrosis

• Congenital Horners

– Heterochromairidis

• Normal light and near reflex

– Slow re-dilation

• Conjunctival vasodilation

• May be increased accommodation