This document provides an overview of neuro-ophthalmology. It discusses the anatomy and physiology of the eye and related structures. Specific topics covered include optic neuropathies like optic neuritis and ischemic optic neuropathy, causes like multiple sclerosis and giant cell arteritis. Cranial nerve palsies of the third, fourth, and sixth nerves are examined. The approach to patients with neuro-ophthalmic complaints is outlined, including relevant history, examination findings, and differential diagnoses. Common pathologies are described along with their typical presentations and diagnostic approaches.

1. Neuro-ophthalmology
Abdulrahman Al-Amri, MD

2. Objectives
• Anatomy& Physiology
• Terminology
– Anisocoria: unequal pupil size
– Papilledema
• Approach as GP
• Pathology
– Optic neuropathy
• Optic Neuritis
• Ischemic optic neuropathy (ION)
• GCA
• Nerve Palsies
– 3rd
,4th
,6th
nerve disorders

3. Anatomy& Physiology

4. Applied anatomy of Afferent & Efferent pupillary defect
Anatomical pathway Signs
•APD
•Loss or diminished reflex
(damaged II)
3rd

5. Efferent pupillary defect (EPD(
– III nerve palsy
– Sphincter pupillae
• Loss of direct and
consensual (damaged III)
• Anisocoria

6. Approach as GP

7. Approach
History
• Visual:
– Loss
• Transient
• Persistent
– Field defect
• Pain
• Diplopia
– Monocular:..
• Tear film
• Cornea and lens
– Binocular:…
• Nerve palsies
• POH
• PMH:
– MS
– CTD
– Gran. Dis
– Drugs:Anti-TB
• SR
– Headache
– Hearing
– Balance
– Speech

8. Examination
• Proptosis
• Eyelid
– Ptosis
– Lagophthalmos
• Nystagmus
• EOM
• VA(BCVA)
• Color vision
• Pupillary reflexes
– Afferent vs Efferent
• Disc
– Edema
– Pallor
– Hyperemia
• Visual Field
– Central scotoma
– Altitudinal

9. Pathology

10. Optic Neuritis
• Age 20-50
• Unilateral
• Worsen over hrs/days
then Recovery starts
• Retrobulbar pain..may
be worse on eye mov.

11. • VA& Color vision
• RAPD
• Disc
– Edema
– Hyperemia
(1/3
of cases)
Central scotoma

12. Dx
Clinical

13. Optic Neuritis
Causes
• MS
• Infectious
– Viral ..
• Toxic
– Investigate:
• CBC,ESR,CRP,
• CXR,Syphilis Serology
• ANA, LFT,U+E
• MRI
– MS…

14. RX:
– Underlying
– IV Steroid

15. Ischemic optic neuropathy
ION
• Old
• Visual loss
• APD
• Disc edema
• Disc: Pallor…Hyperemic

16. Hyperemic Disc Pale Disc

17. ION Non-arteritic Arteritic
Incidence Common
10/100,000
Rare
0.3/100,000
Cause Arteriosclerosis GCA
ESR& CRP N High
TAB -ve +ve
Risk to fellow eye Low High
Rx Aspirin Steroid

18. Papilledema
• Malignant HTN
• SOL
– Tumor
• Trauma
– Cerebral edema/hage
• Pseudotumor cerebri (Idiop.Intracranial HTN)

19. Papilledema Papillitis
• Bilateral
• Gradual
• Transient v. loss
• Blind spot
• Dye leakage-FFA
• Symp of ICP
• SOL on MRI
• Unilateral
• Rapid
• Profound
• Central scotoma
• Dye leakage-FFA
• Symp of MS
• Demyelinatin on MRI

20. Steroid
Tetracycline
OCP
Nalidixic acid
Excess-Vit A derivative

21. OCULAR MOTOR NERVE PALSIES
1. Third nerve
2. Fourth nerve
3. Sixth nerve

22. Anatomy of third nerve
Oculomotor nucleus
Pituitary gland
Carotid artery
Cavernous sinus
III nerve
Clivus
Basilar artery
Post cerebral artery
Red nucleus
Pons

23. Applied anatomy of pupillomotor nerve fibres
Blood vessels on pia mater supply surface
of the nerve including pupillary
fibres ( damaged by
compressive lesions )
Vasa nervorum supply part
of nerve but not pupillary
fibres ( damaged by medical
lesions )
Pupillary fibres lie dorsal and peripheral
SurgicalSurgical
Medical

24. Ptosis, mydriasis
• Limited depression• Limited adduction
• Normal abduction
• Limited elevation

25. Right third nerve palsyRight third nerve palsy
PupilPupil??

26. Watch
Describe what is happening
Where is the problem, and why?

27. Anatomy of fourth nerve
• Only cranial nerve to emerge dorsally
• Crossed cranial nerve
• Very long and slender
Internal carotid artery
Postr. communicating
artery
III
VI
Postr.cerebral artery
Supr.cerebellar artery
Basilar artery
IV

28. Signs of right fourth nerve palsy
• Right overaction on left gaze
• Rt under action on depression
in adduction
• Vertical diplopia
• Rt hyperdeviation in primary
position when left eye fixating
• Excyclotorsion

29. Rt 4th
nerve palsy

30. Anatomy of sixth nerve
Basilar artery
Pituitary gland
Carotid artery
Cavernous sinus
VI nerve
Petroclinoid
ligament
Clivus
Pyramidal tract
Vestibular
nucleus
Medial
lemniscus
4th ventricle

31. Primary position Rt Gaze

32. Straight in primary position due
to partial recovery
Limitation of right abduction and
horizontal diplopia
Normal right adduction

33. DDxDDx
 Nerve palsyNerve palsy
 NMJNMJ
 Myasthenia GravisMyasthenia Gravis
 MuscleMuscle
 TEDTED
 OrbitOrbit

34. Problem solving

35. 33rdrd
pupil problempupil problem
Describe the signs
Where is the problem, and
why?

36. Describe the signsDescribe the signs
Where is the problem, and why?Where is the problem, and why?

37. left

38. Bright lightBright light
 PharmacologicalPharmacological
 Adie’s pupilAdie’s pupil
 TraumaTrauma
 sphincter rupturesphincter rupture
 III nerve palsyIII nerve palsy
 Unlikely if isolatedUnlikely if isolated

39. Dim lightDim light
 PharmacologicalPharmacological
 UveitisUveitis
 Horner’sHorner’s