Neuro-ophthalmology

Comprehensive Factual Review
Wednesday 3/19/08 - 7:00 AM to Noon
Section # W-301

Course Instructors

Module 1: Neuro-ophthalmology fundamentals

Molly Gilbert, MD

 

Anatomy:                                              Bony / Vascular anatomy

                                                            Afferent / Efferent visual pathway

                                                            Autonomic pathways

Examination:                                         Pupillary testing (RAPD)

                                                            Visual fields (confrontation, Amsler grid, Tangent screen, Perimetry)

                                                            Color vision, contrast sensitivity, PST, PAM, FA

                                                            Electrophysiologic testing (VEP, ERG)

                                                            r/o maculopathy (cone-rod dystrophy, AMD, CME, CSR, ERM)

                                                            r/o retinal diseases (CRAO, ischemic CRVO, MEWDS, AZOOR)

 

Neuroimaging:                          CT / MRI - Fundamental concepts in localization

 

Patient with Transient Vision Loss:        Monocular versus Binocular

Monocular –     ocular/orbital, Embolic (amaurosis fugax), vasculitis (GCA), Hypoperfusion, Vasospasm (migraine)

                                                            Binocular -       Migraine, occipital lobe lesions/ischemia/seizures

 

Module 2: Patient with decreased vision & -ive RAPD

Molly Gilbert, MD

 

Decreased vision with normal disc appearance, normal central acuity and no RAPD:

                        VF defects (bitemporal, homonymous)

                        Chiasmal, optic tract, parasellar, temporal /parietal /occipital lobe) lesions

 

Decreased vision with normal disc appearance, decreased central acuity and no RAPD

                        Ambyopia, Toxic/nutritional optic neuropathy, cone-rod dystrophy, paraneoplastic syndromes

                        Cancer-associated retinopathy (CAR), AZOOR

 

Decreased vision with abnormal disc appearance, decreased central acuity and no RAPD

                        Dominant optic atrophy, optic chiasmal glioma, malignant optic glioma

 

Module 3: Patient with decreased vision & +ive RAPD

Molly Gilbert, MD

                                                           

Decreased vision with normal disc appearance, normal central acuity and +ive RAPD

                        Retrobulbar ischemic optic neuropathy

 

Decreased vision with abnormal disc appearance, normal central acuity and +ive RAPD

                        Glaucoma, Optic nerve Drusen (d/d astrocytic hamartoma)

                        Congenital tilted disc syndrome, diabetic papillopathy

 

Decreased vision with disc edema, normal central acuity and +ive RAPD

                        Anterior ischemic optic neuropathy, papillitis, chronic papilloedema,

                        Orbital compression, infiltrative optic neuropathy

 

Decreased vision with normal disc appearance, decreased central acuity and +ive RAPD

                        Retrobulbar optic neuritis, Graves Ophthalmolopathy, traumatic/infiltrative optic neuropathy

                        PION, Leber Hereditary Optic Neuropathy

 

 

 Decreased vision with abnormal disc appearance, decreased central acuity and +ive RAPD

                        Compressive optic neuropathy (optic nerve sheath meningioma, optic glioma)

                        Leber Hereditary Optic Neuropathy, Optic atrophy, optic nerve hypoplasia

                        Excavated optic disc anomalies

 

Module 4: Ocular Movement & Diplopia

Troy Close, MD

 

Patients with Nystagmus

                        Early-onset (childhood) Nystagmus – Congenital nystagmus, Spasmus Nutans

                        Acquired Nystagmus – Gaze-evoked nystagmus, Dissociated nystagmus

                        Nystagmus and Oscillatory movements – downbeat, upbeat, see-saw, periodic alternating

                        Ocular oscillations other than nystagmus – Opsoclonus, Covergence-Retraction nystagmus

 

Pateints with ocular motor disorders

                        Testing: ocular stability, vestibular-ocular reflex, optokinetic nystagmus, pursuit/saccadic

Saccadic dysfunction, ocular motor apraxia, gaze palsy and preference, vestibule-ocular dysfunction, pursuit dysfunction, tonic deviation of the eyes

 

Pateints with ocular Diplopia:    Monocular versus Binocular Diplopia

                        Comitant deviations:

Divergence insufficiency, skew deviation

                       

                        Incomitant deviations :

Primary Overaction Syndromes (superior oblique myokymia, ocular neuromyotonia)

Restrictive Syndromes : Brown syndrome, Grave’s, orbital myositis, congenital fibrosis

Paretic Syndromes :

            Central lesions : Suprnuclear, internuclear, one-and-a-half syndrome, skew deviation

            Subarachnoid peripheral lesions: 3rd, 4th and 6th nerve palsy

            Cavernous sinus & SOF: Tolosa-Hunt syndrome, Carotid-cavernous fistula

Neuromuscular Transmission defecit: Myasthenia gravis

Orbital paretic syndromes: Myopathies, Kearns-Sayre syndrome, Myotonic dystrophy

 

Module 5: Pupillary, Eyelid abnormalities & Miscellaneous topics

James Goodwin, MD

 

Pateints with papillary abnormalities:

                        Anisocoria (pathologic / physiologic)

                        Anisocoria greater in dim light (Horner syndrome, pharmacologic, physiologic)

                        Anisocoria  greater in bright light (Adie’s tonic pupil, 3rd nerve palsy, iris damage)

 

                        Pupillary light-near dissociation: aberrant regeneration of 3rd nerve

 

 

Patients with Eyelid or Facial abnormalities:

Disorders of overactivity of 7th nerve: essential blepharospasm, hemifacial spasm, facial myokymia

 

Patients with Head, ocular or facial pain:

                        Migraine and tension-type headache, cluster headache, trigeminal neuralgia, HZO

 

Patients with functional visual disorders: Examination techniques and management