NEURO-OPHTHALMOLOGY

Clinical Examination
• Visual Acuity
• Colour Vision
• Visual Fields
• Pupils
Normal Eye and Optic Disc

Cupped disc
 The swollen optic disc

•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 y.o. male
Reduced VA
Painless loss of vision
Essential hypertension
Smoker
The pale optic disc
•Congenital
•Secondary to
•raised ICP
•vascular
retinal disease
•optic neuritis
•optic nerve
compression
•trauma
•Glaucoma
 Papilloedema
Blurred optic
• Disc swelling secondary to raised ICP disc margin
• Headache
Haemorrhages
– Worse in the morning
– Valsalva manouver
• Nausea and projectile vomiting
Small optic
• Horizontal diplopia (VI palsy) CWS cup
• Causes
– Space occupying lesion
– Intracranial hypertension Disc pallor
• Idiopathic
• Drugs
• Endocrine
– Severe hypertension

Vessel attenuation
 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)
 Pupil

• Constricted (mioisis) • Dilated (mydriasis)

– Sympathetic – Parasympathetic
(pupillodilator) (pupilloconstrictor)
denervation denervation
– Drugs – Lesion of the third CN
• Pilocarpine – Drugs
• Morphine • Atropine
• Cocaine
 Horner’s
• Oculosympathetic
paresis

– Ptosis
– Miosis
– Ipsilateral anhidrosis
– Does not dilate with
cocaine 4%
 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)
 Internal Carotid Dissection

Herpes
Zoster

CVA
Otitis Media Tumour
Tolosa-Hunt Sy.

Pancoast bronchogenic carcinoma

 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.
 Afferent & efferent defects
• Argyll-Robertson • Miotonic pupil (Adie’s
pupil syndrome)
– Small, irreg – Dilated
– Poor response to light and
– Does not react to light
convergence.
– Reacts to
• Constricts with weak
accommodation
Pilocarpine
– Causes
• Holmes-Adie syndrome
• syphilis
– Reduced tendon reflexes
• diabetes (Knee, ankle)
- Orthostatic hypotension
 Ocular motility abnormalities
• Third nerve palsy • Sixth nerve palsy
– Double vision – Double vision
– Eye turned down & out – Eye turned in
– Ptosis
– Dilated pupil &
headache
• Compressive lesion
Cranial Nerve Palsies
Looking straight ahead
 Posterior communicating artery aneurysm

Chiasma

Posterior cerebral
artery
III CN
 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
 Myasthenia Gravis
• Fatigability
• Double vision
• Lid twitch
• Ptosis
• Normal reflexes & sensation
 INVESTIGATIONS MG
• Anti ACh receptor Ab’s
ACh
• Electromyography
• Tensilon test
– Edrophonium blocks
acetyl-cholinesterase
– Beware of cholinergic
cardiac effects. Use
with Atropine 0.6mg
Anti AChR Ab’s
• Thoracic CT and MRI to
AChR
rule out thymoma
 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