Optic Disc Cupping
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NEURO-OPHTHALMOLOGY
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Clinical Examination
• Visual Acuity• Colour Vision• Visual Fields• Pupils
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Normal Eye and Optic Disc
Cupped disc
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The swollen optic disc
•Papilloedema
•Papillitis
•Malignant hypertension
•Ischaemic optic neuropathy
•Diabetic optic neuropathy
•CRVO
•Intraocular inflammation
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25 y.o. femaleReduced VAPain with eye movementColour desaturationRAPD
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65 y.o. maleReduced VAPainless loss of visionEssential hypertensionSmoker
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The pale optic disc •Congenital
•Secondary to
•raised ICP
•vascular retinal disease
•optic neuritis
•optic nerve compression
•trauma
•Glaucoma
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Papilloedema• Disc swelling secondary to raised ICP• Headache
– Worse in the morning– Valsalva manouver
• Nausea and projectile vomiting• Horizontal diplopia (VI palsy)• Causes
– Space occupying lesion– Intracranial hypertension
• Idiopathic• Drugs • Endocrine
– Severe hypertension
Haemorrhages
CWS
Blurred optic disc margin
Small optic cup
Disc pallor
Vessel attenuation
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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)
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Pupil
• Constricted (mioisis)– Sympathetic
(pupillodilator) denervation
– Drugs• Pilocarpine• Morphine
• Dilated (mydriasis)– Parasympathetic
(pupilloconstrictor) denervation
– Lesion of the third CN– Drugs
• Atropine• Cocaine
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Horner’s
• Oculosympathetic paresis
– Ptosis– Miosis– Ipsilateral anhidrosis– Does not dilate with
cocaine 4%
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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)
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Pancoast bronchogenic carcinoma
Otitis MediaTolosa-Hunt Sy.
CVATumour
Internal Carotid Dissection
Herpes Zoster
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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.
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• Argyll-Robertson pupil– Small, irreg– Does not react to light – Reacts to
accommodation– Causes
• syphilis• diabetes
• Miotonic pupil (Adie’s syndrome)– Dilated– Poor response to light and
convergence.
• Constricts with weak Pilocarpine
• Holmes-Adie syndrome– Reduced tendon reflexes
(Knee, ankle)- Orthostatic hypotension
Afferent & efferent defects
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Ocular motility abnormalities
• Third nerve palsy– Double vision– Eye turned down & out– Ptosis– Dilated pupil &
headache• Compressive lesion
• Sixth nerve palsy– Double vision – Eye turned in
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Cranial Nerve PalsiesLooking straight ahead
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Posterior communicating artery aneurysm
III CN
Posterior cerebral artery
Chiasma
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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
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Myasthenia Gravis
• Fatigability• Double vision• Lid twitch• Ptosis• Normal reflexes & sensation
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INVESTIGATIONS MG
• Anti ACh receptor Ab’s• Electromyography• Tensilon test
– Edrophonium blocks acetyl-cholinesterase
– Beware of cholinergic cardiac effects. Use with Atropine 0.6mg
• Thoracic CT and MRI to rule out thymoma
Anti AChR Ab’s
AChR
ACh
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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
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