- International Council of Ophthalmology

NEURO-OPHTHALMOLOGY
Clinical Examination
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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
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Disc swelling secondary to raised
ICP
Haemorrhages
Headache
–  Worse in the morning
–  Valsalva manouver
Nausea and projectile vomiting
Horizontal diplopia (VI palsy)
Causes
Disc pallor
–  Space occupying lesion
–  Intracranial hypertension
•  Idiopathic
•  Drugs
•  Endocrine
Vessel attenuation
–  Severe hypertension
Blurred optic
disc margin
CWS
Small optic
cup
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)
–  Sympathetic
(pupillodilator)
denervation
–  Drugs
•  Pilocarpine
•  Morphine
•  Dilated (mydriasis)
–  Parasympathetic
(pupilloconstrictor)
denervation
–  Lesion of the third CN
–  Drugs
•  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
Otitis Media
Tolosa-Hunt Sy.
CVA
Tumour
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
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
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
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
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Fatigability
Double vision
Lid twitch
Ptosis
Normal reflexes &
sensation
INVESTIGATIONS MG
ACh
Anti AChR Ab’s
AChR
•  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
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