BASIC NEURO-OPHTHALMOLOGY

60% of our brain is linked to vision

Diseases of the eye and the neurological apparatus
that serves it

Afferent
- Retina
- Optic nerve
- Chiasm
- Tract
- Cortex

***if we are talking about vision, history is important!

- sudden and acute vascular in origin
- gradual, progressive tumor, something that is
compressing
- long duration + associated pain inflammatory

Efferent
- CN 3,4,6
- Ocular muscles
- Brainstem
- Pursuit and saccadic
pathways

Common Problems Seen

- Loss of vision (transient, constant, mono/binocular)
- Diplopia
- Ptosis
- Visual disturbance
- Pupil irregularities
- Motility disorders
- Eyelid or facial spasms
Considerations
- Where is the lesions
- What is the lesion
- When did it start
- How did it present
-

Urgent
Emergent

***Eye movement CN 3, 4, 6 + CN 5, 7, 8
***Meyers loop while it goes to the optic radiation..some
fibers go up to the parietal lobe and some fibers go to the
temporal lobe before it actually goes to the occipital lobe
***pupillary light reflex it ends in the pretectal nucleus
and it does not go all the way to the occipital lobe, so you can
be occipitally blind but you still have pupillary reaction.
Afferent System Diseases
- optic neuritis
- ischemic optic neuropathy (arteritic vs. non
arteritic)
- Toxic optic neuropathy (e.g. ethambutol toxicity)
- other optic neuropathies (compressive,
papilledema, inflammatory, hereditary)
- chiasmopathies/chiasmal disorders
- stroke that causes defects in the visual field

***direct pupillary light reflex reaction of the eye being

tested
***consensual pupillary light reflex reaction of the
opposite eye or the eye not being tested
Afferent System

Loss of Vision
- History: sudden or chronic
- Check visual acuity
- Check for relative afferent pupillary defect
- Do a visual field by confrontation
- Color test
- Ophthalmoscopy

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Papilledema
- Optic nerve head swelling
- Normal visual acuity
Vision
- Visual acuity
- Color test
- Double vision
***if a patient come to you with a complaint of double vision
and disappears after covering one eye investigate but if
double vision still persists can be an error of refraction
***in ishihara book, number 12 is the most important thing
b/c both normal and colorblind person can see the number
12 and when the patient tells you that he/she cant see
even the number 12, then theres really a problem.
***red is best color to test for desaturation
Confrontation Fields

***always draw it how the patient sees it and always plot the
physiologic blind spot.. blind spot is always located
temporally.
***temporal side is always bigger than the nasal side b/c
there are 53 decussated fibers and 47 undecussated fibers
***in pediatric, ask him/her to copy you to assess visual
perimetry
Relative Afferent Pupillary Defect (RAPD)
- Normal response
- theres consensual light reflex but theres no direct
light reflex on the affected eye
- can be caused by optic neuritis, or tumor anterior to
the chiasm

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to test it, ask the patient to look at a distance and do

it fast (Marcus Gunn test/ swing light test)
Normal reaction when light is shined on one eye
both eyes constricts

***When the eyes look at a near object, three responses

occur accommodation, convergence, and constriction of
the pupil bringing a sharp image into focus on
corresponding retinal points.
Optic disc
- look for disc borders, hemorrhage, color (if pale),
cup-disc ratio (reported as 0.3, 0.5 etc.)
***pale optic discatrophy(20% have tumor)
***In papilledema, there should be increase ICP if there is
no mentioned increase ICP, label it as optic head swelling or
disc edema
***normal ICP = 15-25 mmHg
***pallor vision affected > 6 weeks
TYPICAL OPTIC NEURITIS
- sudden vision loss with optic disc swelling
- pain with eye movements
- females > males
- RAPD present
- Optic disc normal (2/3)
- brown hair, blue eyes observe for few weeks
- typically found in Caucasian people
- age b/w 15-45y/o
- it is associated with MS
- In the Phils, most common cause is inflammatory or
infectious
- Unilateral
- Pain
o Pain on eye movements
o First symptom to appear and disappear
- Rs in Optic Neuritis
o Radiology
MRI is only done to see white
matter lesions to confirm MS (75%
over 15 yrs)
More lesions increased risk of
developing MS
o Recovery
IV steroids only hasten recovery
but not final VA outcome
o Risk factors
20-40 y/o, female, white, family
history of MS
o Recurrence
Higher with those given with oral
steroids (standard doses)
- If it is typical optic neuritis OBSERVE
- Most common symptom: pain on eye movement
- Most common VF defect: DIFFUSE
***In typical optic neuritis, w/ or w/o treatment, in a matter
of few weeks, your patient will improve

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***In atypical optic neuritis, does not improve for a month;

should be seen by neuro-ophthalmologist
***Oral steroids increase recurrence so the definitive
management is IV steroids
***2/3 of cases of optic neuritis, optic cup: disc ratio appears
normal but in children, it always appears swollen with
hemorrhage
***Neuromyelitis optica bilateral optic neuritis with
transverse myelitis; give steroids
Ischemic Optic Neuropathy
- common among people age >50 y/o
- acute, painless loss of vision
- vasculopathic risk factors such as diabetes (number
1 risk factor), hypertension and high cholesterol
- RAPD present
- has decrease cup: disc ratio esp. in the presence
of cholesterol plaque fibrin plaque ION always
present with hemorrhage
Non Arteritic Ischemic Optic Neuropathy
- ischemic problems at the short posterior ciliary
arteries
- usually occurs in the morning
- commonly altitudinal field loss
- check for vasculopathic risk factors
- recurrence less likely
- no proven treatment
- 2nd eye involvement is 15-30%
- Disk at risk appearance
Arteritic Ischemic Optic Neuropathy
- patients > 60 y.o. (older age group)
- headache, malaise, myalgia, weight loss, fever, jaw
claudications and transient loss of vision
- Labs: ESR, CRP high
- Temporal artery biopsy
- > 3 cm is needed due to skip lesions
- giant cell arteritis
- immediately give high dose steroids or else the
patient can go blind or patient may die b/c there are
active inflammation of all blood vessels
- do temporal artery biopsy, get about 3-5cm
specimen b/c there are skip lesions
- patient always present with severe pain, headache,
malaise, weight loss (b/c patient has jaw
claudication every time the patient tries to eat
patient has to change his/her diet)
- normally present with disc pallor
Compressive lesions
- slowly progressive loss of vision
- can be unilateral or bilateral
- pituitary tumors, craniopharyngiomas and
meningiomas of the skull base
- require MRI for diagnosis

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***optic neuritis visual loss can be anywhere

***non-arteritic ischemic optic neuropathy visual loss is
always altitudinal
***arteritic ischemic optic neuropathy visual loss can be
anywhere but the appearance of the disc together with the
field defect will give you the diagnosis. color vision is
important.
***compressive enlarged blind spot
Color Vision
***the patient will complain of something wrong with
his/her vision and the grade is about 20/30 but if you ask
him/her to read the ishihara book, he/she cannot see
anything but if you ask the patient to close the other eye,
he/she can read on the plate so the ishihara book will
actually tell you that there is an ongoing process on the optic
nerve
***color vision is a very soft predictor that the optic nerve is
affected. Its the first thing to go. But books will always tell
that it is visual field loss is the first marker.
Central Retinal Artery Occlusion
- painless loss of vision
- may be preceded by Amaurosis Fugax
- source of emboli usually carotid or cardiac

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less common causes: vasculitis (GCA, Antiphospholipid syndrome)

- Order Carotid Doppler Study and Echocardiography
***cherry red spot can be seen in CRAO, Tay-sachs disease,
Gauchers disease
Papilledema
- Disc edema d/t increased ICP (mass, pseudotumor
cerebri)
- Headache, transient visual obscurations, diplopia,
tinnitus
- Normal visual acuity and visual fields early
- Ophthalmoscopy
- Imaging
Idiopathic Intracranial Hypertension (pseudotumor
cerebri)
- women > men (9:1) in child-bearing age
- 90% of affected women obese
- Normal CT/MRI/MRV and CSF analysis
- Recent weight gain (lost 6 months)
- Medication-linked: Tetracycline for acne, oral
contraceptives, insulin-like growth factors in
children
- Aim of treatment: stop progressive loss of vision
(Diuretics and Surgery)
Visual Field Defects

***pie in the sky defect (superior quadrantinopsia) lesion

in the fibers going to the temporal lobe
*** pie in the floor defect (inferior quadrantinopsia)
lesion in the fibers going to the parietal lobe
***more congruous homonymous hemianopsia lesion is
more on occipital lobe
***increase ICP disc swelling + CN 6 problem
***pseudotumor everything is normal but patient is
losing his/her vision and there is lateral disc swelling the
problem is on the drainage system, either insufficient
drainage or there is overproduction of CSF commonly seen
in fat, forty, female
***in IOH, sometimes, disc swelling may appear after 2
weeks
EFFERENT SYSTEM DISEASES
- Diplopia
- CN palsy
- Multiple CN palsy
- Abnormal eye movement
- Myasthenia gravis
Diplopia
- Key question:
o Is it only in one eye?
o Does it go away when you close either eye?
- Monocular diplopia is always refractive in origin
(cataract, astigmatism)
- Examine lids and pupils in addition to eye
movement
- Examine all CN
- Check V1(corneal sensation), consider cavernous
sinus problem
***if a patient come to you with a complaint of double vision
and disappears after covering one eye investigate but if
double vision still persists can be an error of refraction
Cranial Nerve 3, 4, 6
- can be a vasculopathic cranial nerve neuropathy
- demyelinating disease
- compressive
- trauma
- increased ICP

Ethambutol Toxicity
- can present with bitemporal hemianopsia
***any lesion posterior to the chiasm always
homonymous
***anterior to the chiasm one eye is only affected

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Oculomotor Nerve (CN3) palsy

- eye is looking down and out + ptosis
- check for pupillary light reflex will tell you the
urgency of the case
- patient may have aneurysm ..and the first sign of
aneurysm is a CN3 problem + pupillary involvement
and the most common site of aneurysm is at the
junction of the PCOMM.
o Ruptured aneurysm 70% mortality
Abducens Nerve (CN6) palsy
- Anatomical facts:

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Origin of CN 6 w/c innervates lateral rectus

but also gives fibers w/c eventually end at
the contralateral medial rectus
most common nerve affected by raised pressure
diplopia at distance face turn to one side will
relieve double vision
o

Trochlear Nerve (CN4) palsy

- only CN which exits dorsally
- thinnest
- longest intracranial course 75 mm
- only CN which crosses opposite side
- oblique diplopia
- the patient will complaint that one image is higher
than the other
- to relieve double vision patient will tilt his/her
head
- Parks-Bielschowski 3-step test
***if the patient is >50y/o, diabetic, hypertensive, has high
cholesterol, smokes a lot, drinks a lot and only 1 cranial
nerve is affected dont do anything, just put foil on one eye
and ask them to return after 2-3 months b/c normally this
will resolve spontaneously even without treatment
Multiple Cranial Nerve Neuropathies (3,4,6)
- Ischemic CN neuropathies are almost always
isolated
- If multiple simultaneous CN, suspect lesion in
posterior orbit/cavernous sinus region
- Usually d/t mass lesion
***cranial nerves are all bunched up in the brainstem and
the cavernous sinus.. so any lesion affecting these areas will
affect the cranial nerves.
Ocular myasthenia
- Myasthenic signs restricted to ocular muscles
- Fatiguable diplopia and ptosis
- first sign of MG, >70% of the cases, are with eye sign
- ice test or rest test in the clinic demonstrate
improvement
- acetylcholine receptor antibodies (positive in 50%
only)
- single fiber EMG
- tensilon test
Myasthenia Gravis
- great mimicker can mimic any cranial nerve
problem
- hallmark: variability and fatigability
- mechanism: autoantibodies directed against Ach
receptors are produced and destroy and block a lot
of receptors
***ice test in the eye (+) if the patient can open his/her
eyes after application of ice
***in pediatric MG, patient should take mestinon until they
are 8 y/o
***in doing tensilon test, give atropine b/c one S/E of
tensilon is cardiac arrest
- natural pattern

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present with diplopia or ptosis

80% may start to develop systemic
weakness w/in 2 yrs
Optical treatment
o Prisms
o Occlusion
Medical
o Pyridostigmine (mestinon)
anticholinesterase
o Prednisone
Suppresses autoimmune process
o Steroid sparing drugs
Surgical
o Thymectomy
o Ptosis and strab
Must be stable, longer, better
Must be informed properly
o
o

CLUES IN DIAGNOSING DIPLOPIA

- Variability and fatigability MG
- Distance CN 6, IIH, ICP
- Near CN 3, INO
- Down and Out CN 3
- Monocular error of refraction
- Tilting CN 4
- Multiple CN MG, CST
PUPILLARY ABNORMALITIES
- Anisocoria
o unequal pupil size
- it can be accidental discovery
- physiologic in 40% of patients
- it can be isolated or associated with lid or ocular
motility abnormalities
- can be iatrogenic or self-induced (pharmacologic)
Horners Syndrome
- a defect in oculosympathetic flow to the eye (pupil
does not dilate in dark)
- TRIAD: ptosis, anhydrosis, miosis (worst in dark)
- Internal carotid artery dissection, neck trauma or
surgery, brainstem strokes (Wallerburg Syndrome),
apical lung tumors
- Urgent MRI/MRA of the head and neck for acute
Horners Syndrome
***one horny pam from coast
one = T1 lesion
horny = Horners
pam = triad
coast = pancoast tumor
***Horners syndrome, sudden onset + pain think of
dissecting aneurysm
***diagnosis:
- Testing topical cocaine in the conjunctival sac
differentiates Horner's syndrome, in which the
pupil does not dilate, from physiologic anisocoria.
- Testing with hydroxyamphetamine drops will
localize the lesion

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OCULOSYMPATHETIC PATHWAY
ICE BREAKER!!!
English pick-up lines:
Boy: Did they just take you out of the oven?
Girl: No, why?
Boy: Because youre hot!
You must be a magician, because every time I look at you,
everyone else disappears.
If I were an Azkal, then you are my goal.
If I were a gardener, I would put my tulips and your
tulips together.
HORNERS

You really shoudnt wear makeup, youre messing with

perfection.
I don't need marijuana, I don't need cocaine. Your presence
is enough, to drive me insane.
Tagalog pick-up lines:
Pera ka ba? Kasi naghihirap ako pag wala ka.
Hinding hindi ako mahuhulog sayo, dahil para akong
lumulutang pag nakikita kita.
Ang liit lang pala ng kamay mo pero hawak mo ang mundo
ko.

Adies/Tonic Pupil
- Damage to the ciliary ganglion and/or short ciliary
nerves
- Sluggish or no reaction to light
- tested in a well-lighted room
- Hallmark:
o delayed dilation after constriction
o segmental constriction BAG OF WORMS
o constricts to 0.125% pilocarpine
- DTRs may be affected ADIE-HOLMES
- LIGHT NEAR DISSOCIATION
- initially presents with dilated pupil but will later
become constricted.
CLUES IN DIAGNOSING ANISOCORIA
- dark > bright HORNERS
- bright > dark ADIES
- dark = bright = accommodation PHYSIOLOGIC
- dark = bright < accommodation LIGHT NEAR
DISSOCIATION
- Anisocoria +/- CN3 ANEURYSM
It should always come to mind that treatment with
experience without theory is unsighted therapy, but theory
without experience is mere intellectual tragedy to which the
patient is always the recipient.

G & Baby D

Sana gitara ka na lang, para habang kumakanta ako, yakap

yakap kita.
Sana eroplano ka na lang at airport ako, para kahit anong
mangyari, sakin pa rin landing mo.
Doktor ka ba? Kasi gusto kong sabihin ang nararamdaman
ko.
Sana hindi ka buwan para hindi mo ako iwan pagdating ng
araw.

Ive missed more than 9000 shots in my career. Ive

lost almost 300 games. 26 times Ive been trusted to

take the game winning shot and missed. Ive failed
over and over and over again in my life. And that is
why I succeed. Michael Jordan
GOD BLESS SURGICAL BLOCK 2015

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