Neuro Opt HalmOlogy
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Transcript of Neuro Opt HalmOlogy
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Neurotutorial15 October 2015
Cranial neuropathy part INeuroopthalmology
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Cranial neuropathy
Mononeuropathy
Monocular visual loss
Horner syndromeIsolated 3,4,6 palsy
Vestibular palsy
Trigeminal neuralgiaFacial n palsy
Multiple neuropathy
Cavernous sinus syndrome
et.al
Cerebellopontine angle syndrome
et.al
Jugular foramen syndrome
et.al
With long tract sign
Weber syndromeet al
Millard Gruber syndrome
et.al
Wallenberg syndrome
et al
Exclude Apraxia, NMJ, Muscle
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• Female 40 year old with UD hypertension complaints progressive Rt.eye pain on eye movement for 5 days with central blurry vision. Examination found pupil 2 mm both eyes but poorly react Rt.side. Rt. VA 20/60, Lt VA 20/20. Eye ground exam have no papilledema or exudate. MRI with gad of brain is normal. What is the most appropriate management.
A. ASA 300 mg B. Oral prednisolone C. Observe and FU 3 weeks. D. Intravenous methyprednisolone
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Optic neritis
• Monocular visual loss • Anterior to optic chiasm• Impaired VA• Impaired light reflex
• Binocular visual loss
• Retrochiasm• Not impair VA (unless bilat lesion)• Not impair light reflex ( Retrogeniculate body)
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Blurr disc – hard to diff from papilledema ( usualy bilat involve)
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Acute monocular visual loss
Typical for MS*
Demyelination
High risk for MD(60-90%)
Normal
Low risk for MS. (20%)
MRI brain +/- LP
Atypical for MS
Work up for mimickerLP, Serology, CT/MRI
Clinical,Eye ground
Adapted from Bermel RA, Continuum . 2013 Aug;19(4 Multiple Sclerosis):1074-86
IVMP: if VA worse than 20/40, disabling scotoma,severe pain
• NMO (more bilat, less pain,less recover)• Ishemic : AION• Inflamatory : esp Giant cell arthritis• Infiltrative : Malignancy• Infection : Syphilis, CMV neuroretinitis• Hereditarty
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• Unilat • Pain on movement• Partial : color, contrast, scotoma• Normal disc (most) or mild swelling• Progressive days to weeks
Typical sign and symptom of MS optic neuritis
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IVMP in optic neuritis
• IVMP 250 mg, 6 hourly 3 days,followed by Oral pred (1 mg\kg\d) 11 days tapering of prednisolone within 3 days
• The optic neuritis ONTT -compares oral placebo, IVMP, Oral stearoid
• IVMP -> Faster recovering vision (but no long term impact)-> Slower progress to be definite MS
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Male 70 years-old complain shoulder and headache for 1 dayThe eye examination as the picture. The Lt. pupil is reactive but delayed dilatation after dimmed light. Other wise examination is normalWhat would be investigation of choice.
A. Chest X-rayB. US carotid a.C. CT brain angiogramD. CT brain with contrastE. Refer ophthalmologist for cocain test
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Horner syndrome
Sympathetic paralysis -> look lazy - Mild ptosis - Mild anisocherea :dilate lag in the dark - May anhidrotic : 1st and 2nd order
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Anisochorea = Inequal pupil
• Sympathetic -> dilate eye in the dark Defect side -> dilation lag“ Aniso in the dark”
• Parasympathetic -> constrict in light
Defect side -> Non react dilated “Aniso in the light”
• Physiology = no change
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Anisochorea
• Anisochorea never caused by optic nervedue to consensual reflex: if optic n. defect -> smaller pupil both
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Aniso in the dark: Sens 70% Spec 95%
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Aniso in the light + Non reactive pupil
After mydriasin drop
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No change
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Horner syndrome
1st : Descending tract from hypothalamus:intermediolat corlumn near corticosponal tract
2nd : Preganglionicapical lung - ciliospinal center of budge C8
3rd : Post ganglionicbifurcate of internal and external carotid a.
1
2
3
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Any combination of ptosis, miosis or anhidrosis -> suspect Horner syndrome (HS)
Acute onset , Painful, Trauma, UD Malignancy
Without long tract sign
2nd or 3rd HS-> CTA/MRA E:
HS protocal
With long tract sign
1st order HS-> MRI brain E.
Chronic
Confirm by Cocain & Methylphenidate
Delayed dilation in the dark
Adapted from Davagnanam I ,Eye (Lond). 2013 Mar;27(3):291-8
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Pharmacologic test
Specificity 100%
But need 24 hrs for testing
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Female 50 years-old underlying diabetes complain painless diplopia when look to the right side for 1 week. The eye examination in primary position as the picture. EOM limited adduction 60%, upgaze 80% downgaze 80%. The Rt pupil is 3 mm while Lt. 4 mm sluggish react to light. Other wise examination is normal.What would be investigation of choice.
A. FBSB. Ice pack testC. CT brain angiogramD. CT brain venogramE. CSF for NMO antibody
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Isolated 3rd nerve palsy
Oculomotor n. go along with parasym - Ptosis - Opthalmoplegia - May dilated and non react to the light : 20% of vasculopathy 80% of compressive -> severity of pupil involvement usually correlate with severity of opthalmoplegia
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PCOManeurysm
3rd nerve palsy almost always consider imaging R/O PCOMpupil sparing in ‘partial’ ophthalmoplegia cannot R/O
only pupil sparing in ‘complete’ opthalmoplegia likely R/O
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Isolated 4th nerve palsy
Oculomotor n. go along with parasym - Ptosis more obvious - Opthalmoplegia - May dilated and non react to the light : 20% of vasculopathy 80% of compressive -> severity of pupil involvement usually correlate with severity of opthalmoplegia
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Isolated 6th nerve palsy
Oculomotor n. go along with parasym - Ptosis more obvious - Opthalmoplegia - May dilated and non react to the light : 20% of vasculopathy 80% of compressive -> severity of pupil involvement usually correlate with severity of opthalmoplegia
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Binocular diplopia
Isolated CN 3 palsy
Without long tract sign
2nd or 3rd HS-> CTA/MRA E:
HS protocal
With long tract sign
1st order HS-> MRI brain E.
Isolated CN 4 palsy
DM, HTFU 3-6 mo
Isolated CN 6 palsy
WU focused malignancy
Adapted from Davagnanam I ,Eye (Lond). 2013 Mar;27(3):291-8