1. Neuro ophthalmology Girls work from Dr.Sameerjamal lectures records 2010

2. Neuroophthalmology • It’s the since that study health and disease of the brain and the cranial nerves that involved with the eye. • We have 7 CN that involved (2-8)

3. Visual pathway الدكتور قال لازم نعرف

4. Important topics : • Optic nerve swelling • CN palsy. • Anisocoria: it’s an unequal size of the pupils. • It can be : 1- physiological 2- pathological (due to that reason we should see the size and symmetry of the pupils on examination) • Major causes of Anisocoria: • 3rd CN palsy (neurological disease give us a big pupil) • horner's syndrome (neurological disease give us a small pupil) NB: how to differentiate between them ? 3rd CN palsy: • Limitation of the eye movement • Pupil and other muscles are affected. • +/- ptosis horner's syndrome : • only ptosis • Intact motility

5. Common causes of Anisocoria: 1- Drugs: • pt. may takes pupil dilation drops as in Iritis( to make the iris not stick to the lens) • drops that used at clinic for fundoscopy examination. • pt. used pilocarpine for Glaucoma it will constrict one eye and dilate the other eye. 2- Trauma : particularly surgical trauma is more common than the non surgical one. - So if there’s no history of Drugs used or trauma that means Anisocoriais due one of the major causes and it’s serious.

6. ON swelling • Symptoms: • Decrease visual acuity. • Visual field changes. • Dyschromatopsia: color vision changes. NB: when pt. complain of disturbance in vision think 1st of the common diseases and use the pin whole test , if the pt. vision get better so it’s RE. But if it’s not it means it’s organic ( neurological or mediaعتم الوسائط البصرية ) • Media ( cornea , lens and vitreous ) , the Red reflex test by the ophthalmoscope it will appear abnormal if the media was affected. • Neurological ( optic nerve , retina , chiasm , visual pathway) We have : • Anterior visual pathway: Retina + ON the loss will be in the same side. • Posterior visual pathway: Chiasm and beyond that it must be bilateral loss. • So , Bilateralism + visual field changes + color vision changes = indication of neurological visual loss

7. As a GP u have to recognize and differentiate between : 1- ON swelling 2- ON atrophy 3- ON cupping.

8. 3rd nerve palsy If the patient had paralysis of the eye muscles he will complain of : • Symptoms : 1- binocular diplopia: it’s apathognomonic for paralysis.يعني المريض لما تكون عينو مفتوحة يشوف الحاجة اثنين ولما تكون مغمضة يشوفها واحد 2- abnormal head posture (AHP) : it’s not pathognomonic. • signs: 1- AHP (it’s symptom and sign) 2- ptosis 3- hypotropiaالعين نازلة عكس الرابع 4- limitation of eye movment 5- incomitance it’s a (pathognomonicمهمة جدا ) الانسان الطبيعي عينو تكون متوازية لما يطالع في كل الجهات اما المريض الي عندو حول لما يطالع في اتجاهات مختلفة الحول يتغير ده يكون Incomitance اما لو طالع في اتجاهات مختلفة وبنفس الانحراف ده يكون comitance يعني مو شلل 90 % of squint pt. not havingparalysis 10 % of them having paralysis NB: in 3rd nerve palsy u have to take the age and pupil of the pt. into ur consideration. • In young pt. with 3rd n palsy is intracranial aneurysm until prove otherwise. So u have to admit the pt. regardless the pupil is on or off

9. 4th CN palsy • Symptoms : • AHP • binocular diplopia • Hypertopiaعكس الثالث (due to superior oblique muscle paralysisهيا وظيفتها تسحب العين لتحت لما تنشل العين حتطلع لفوق • Sings: نفسها حق الثالث • Most of them are congenital

10. 5th CN palsy • hyposthesia (less sensation) • Hypersthesia (hypersensitivity in the area of distribution of ophthalmic division of trigeminal nerve) • Spontaneous idiopathic pain without reason (trigeminal neuralgia). 6th CN palsy • Limitations of abduction • 50% of the pt. with 6th nerve palsy is due to intracranial tumor. So as a GP you have to look for any brain tumor or papilledema.

11. 7th CN palsy • Lagophthalmous.المريض مايقدر يقفل عينو Because orbicularis muscle is supplied by facial nerve. • Tears all the time . NB: you have to lubricate the pt. eye to avoid dryness and loss of vision. 8th CN palsy • Imbalance it may be due to ( ocular, neurological, vestibular) causes. • It’s rare due to ocular.

12. Nystagmus • It’s : • Involuntary • Rhythmic : العين تسوي نفس الحركة بإستمرار • Oscillation : tremor of the eye • Of one or both eye. Nystagmus types

13. Our rule as GP we have to make sure that the pt. with Nystgmus is not due to neurological causes by : 1- onset: if it’s new it may be neurological. 2- oscillopsia: يشوف الدنيا مهزوزة مو زي الدوخة نفس الصورة كلها مهزوزة 3- vertical Nystagmus: is more likely to be neurological than horizontal. - Majority of pt. have horizontal Nystagmus. 4- primary position Nystagmus. • In gaze position Nystagmus is less serious than primery. NB: in gaze position يعني اشوفها لما المريض يكون على الجنب

14. DD of ON swelling: All of them will complain of headache & pain. 1- malignant hypertension: • As a GP u have to take the BP of the pt. by ur self if it was high it confirm the diagnosis. • so., u have to call the medicine department and refer the pt. for them to stabilize his Bp. ( high Bp or sudden drop of Bp it will damage the optic nerve). - When the Bp of the pt. get stabilized we have to refer the pt. to the ophthalmologist before six weeks to make sure of the ON Is back to the normal.لان ممكن كمان لما ينزل ضغط الدم يأثر على العين - If the pt. was normal so we have another three DD to think of.

16. If the pt. doesn’t have visual loss or high BP so we think of 4- papilledema • It’s unilateral or bilateral ON swelling due to increased IOP by (tumor, infection or hemorrhage…ect). • This pt. will need CT or MRI first. • Then LP (because of coning) عشان لو المريض عندو ورم وانا عملت LP قبل مااتأكد ممكن يحصلو Coning - If any thing appear abnormal u have to refer the pt. to the ophthalmologist. - If the pt. was normal after the CT and LP so it may be pseudotumorcerebri, confirm it by “CSF opening pressure”. NB: when u do LP take CSF tap + opening pressure The normal CSF pressure for adult (200 ml water or 20 cm ) - If the pt. have pseudotumorcerebri you have to call the ophthalmologist. Because ON swelling if it left untreated for 4-6 weeks it will result in optic atrophy then permanent blindness.

17. Sings of ON swelling (ophthalmoscope) • You must have more than one sign to diagnose ON swelling: 1- sensation of elevation. Focus retina and fuzzy optic nerve. 2- blurred margin 3- hemorrhage in nerves. 4- white exudates. 5- absent of the cup. 6- absent spontaneous nerve pulsation.

18. ON atrophy • Pale color for the optic disk is the characteristic feature of ON atrophy. • Because the blood vessel in the ON when it dies it become atrophied. • ON atrophy is the end stage of all ON diseases , it will lead to permanent loss. • The most common optic neuropathy that cause optic atrophy is Glaucoma.

19. Normal cup • Cup is devoid of nerve tissue . • In glaucoma this white area will increase in size because the nerve fibers will die in the RIM and the blood vessel it will become white >> enlarged cup optic cupping

20. معلومات شرحها على صور • AHP is whole mark for paralytic squint. • Vestibulo ocular response: is a reflexeye movement that stabilizes images on the retina during head movement by producing an eye movement in the direction opposite to head movement, thus preserving the image on the center of the visual field • الدكتور شرحها على صورة واحد راسو مايل لليمين عشان عندو Rt. Lateral rectus palsy (6th n palsy) • Most common cause of AHP in children and young adult without trauma is paralytic squint. • Head tilt is noticed by the Ear but the face turn noticed by chin.

21. ادعولي