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Neuro-ophthalmology – First Contact
- 1. Michael Burdon Queen Elizabeth Hospital Birmingham Neuro-Ophthalmology: First Contact
- 2. Declarations of Interest • Financial: none • Professional: – President, Royal College of Ophthalmologists – Consultant Ophthalmologist – Chairman, NICE Cataract Guidelines
- 3. Outline • Key features of the neuro-ophthalmic history and examination • Conditions that require immediate investigation and treatment
- 4. Afferent Pathway: loss of vision • Papilloedema • Stroke
- 6. Afferent Pathway: History • One or both eyes • Nature of visual loss – dimming – field loss – blurring • Onset – sudden – gradual – transient • Associated symptoms – pain – double vision – weakness/loss of sensation • Past medical history – neurological disease – tumours • FH/SH • Medications
- 7. Afferent Pathway: History • One or both eyes • Nature of visual loss – dimming – field loss – blurring • Onset – sudden – gradual – transient • Associated symptoms – pain – double vision – weakness/loss of sensation • Past medical history – neurological disease – tumours • FH/SH • Medications
- 8. Afferent Pathway: Examination • Function – Visual acuity – Pupils (RAPD) – Colour vision – Visual fields • Structure – Tear film ↓ – Optic disc
- 10. Normal Pupil Response to Light dark light in L eye light in R eye R L
- 11. Left Optic Nerve Damage
- 12. Pupil Response to Light with Left Optic Nerve Damage dark light in L eye light in R eye R L
- 13. Relative Afferent Pupil Defect • Caused by optic nerve damage • Not caused by: – Cataracts – Macular disease – Neurological disease beyond the optic nerve • Test everyone
- 14. The Visual Field “All the space that one eye can see at any given instant” (Tate and Lynn 1977)
- 15. Confrontation Visual Field Testing • Gross screening test • Able to detect – Hemianopia – Quadrantinopia – Altitudinal field defect
- 16. Confrontation Visual Field Testing X X X X
- 17. Confrontation Visual Field Testing X X X X
- 18. Confrontation Visual Field Testing X X X X
- 19. • Papilloedema
- 20. Papilloedema • Optic disc swelling due to raised intracranial pressure
- 21. • Brain abscess • Meningitis • Tumours • Hydrocephalus • Venous sinus thrombosis • Subarachnoid haemorrhage • ... • IIH Papilloedema - Aetiology
- 22. Papilloedema - Presentation ± Headache ± Diplopia ± Obscurations ± Photopsia ± Nausea / vomiting ± Pulsatile tinnitus ± Localising symptoms
- 23. Papilloedema Pathway Casualty Patient Optom GP Neurology - Imaging - Lumbar puncture
- 24. Papilloedema: First Contact • Priority in A&E • Doctor to confirm if disc swelling consistent with papilloedema • If possible arrange – Perimetry – OCT of optic discs (including peri-papillary RNFL) • Refer to on call neurology team
- 25. • Stroke
- 26. NICE - Stroke Guidelines • Admission to a specialist acute stroke unit • Immediate imaging • Treatment – thrombolysis /clot retrieval + antiplatelet & anticoag (6 hours) – decompressive hemicraniectomy + antiplatelet & anticoag – intracerebral haemorrhage management • Secondary stroke prevention & rehabilitation NICE CG68 last revision May 2019
- 27. NHS “FAST” Campaign Visual Loss?
- 28. Hemianopia - Thrombolysis • 6 patients with posterior cerebral artery stroke – 4 with hemianopia • Intravenous thrombolysis (0.9mg/kg rtPA) • Symptom onset to treatment 185 to 390 minutes • Resolution of heminanopia in 3 out of 4 patients Förster A et al. AJNR 2011 32(2):419-421
- 29. Hemianopia - Thrombolysis • Three patients with homonymous hemianopia due to posterior circulation stroke • Intravenous thrombolysis following CT scan • At six months: – Two: normal Goldmann fields – One: “modest” visual field defect Strbian D, et al. Acta Neurol Scand 2012 126 e17-19
- 30. Stroke: First Contact • Good history and confrontation field at A&E triage • If stroke suspected: – Immediate confirmation by A&E doctor – Immediate transfer to stroke team
- 31. Efferent Pathway: double vision • Third Cranial Nerve Palsy
- 32. Causes of Double Vision Monocular Diplopia Binocular Loss of fusionMotility Disorder Vergence Brainstem Peripheral N-M junction Muscle/orbit Optical Macula Cortical Psychogenic Sensory Motor
- 33. Optical Diplopia “Does the double vision persist if one or other eye is covered?”
- 34. Optical Diplopia “Does the double vision persist if one or other eye is covered?”
- 35. Optical Diplopia: Effect of Pinhole
- 36. Diplopia: History • Orientation (horizontal, vertical, torsional) • Variation with eye position • Onset • Progression • Constant/Intermittent/Variable
- 37. Diplopia: History • Past medical history – Ophthalmic – Neurological – Tumours – Diabetes – …. • Medications – Epileptics – Statins – Penicillamine – …. • Systems review • Neurologic – Headache – Weakness – ¯ Sensation – … • Ophthalmic – Head position – Proptosis – Ptosis – Anisocoria – Pain / pain on eye movement – Visual loss
- 38. Motility Disorders Eye Movements • Fixation • Saccades • Pursuit • Vergence • VOR/OKN Localisation • Vergence • Brainstem • Peripheral • N-M junction • Muscle/orbit
- 39. Fixation • Examine patient’s ability to maintain fixation on a target in both the primary position and eccentric gaze
- 40. Fixation • Examine patient’s ability to maintain fixation on a target in both the primary position and eccentric gaze ? Steady ? Nystagmus
- 41. Alignment • Cover test (manifest deviation: tropia) • Alternate cover test (latent deviation: phoria) • Light or accommodative target? • Near, distance, eccentric gaze?
- 42. Alignment • Cover test (manifest deviation: tropia) • Alternate cover test (latent deviation: phoria) • Light or accommodative target? • Near, distance, eccentric gaze?
- 45. Ductions and Versions • Torch (observe corneal reflexes) • If limitation observed compare duction with version – Restrictive: duction = version – Paralytic: duction > version
- 46. Saccades • Two targets – Horizontal – vertical ? Slow - brain, nerve, muscle ? Hypo- or hypermetric – brainstem or cerebellar disease ? Fatigue
- 47. Convergence • Test with accommodative target or patient’s finger ? Convergence > adduction – INO
- 48. Eye Movement Examination • Visual function • Pupils • Cranial nerves II to VIII • Fundoscopy • +/- PNS examination (additional neurology usually localises the palsy)
- 49. Questions • What is the eye movement abnormality? – Unilateral imitation of abduction – Bilateral failure of up-gaze – … • What could cause the observed eye movement abnormality? – Vergence – Brainstem – Cranial nerve – Neuromuscular junction – Muscle/orbit
- 50. Cranial Nerve • III (SR, MR, IR, IO, LPS, Sphincter pupillae, ciliary body) • IV (SO) • VI (LR) • Isolated? • Localisable? – V, VI, VII, & VIII – CPA angle – II, III, IV, Va,b, VI, Horner's – Cavernous sinus / orbital apex
- 51. • Third Cranial Nerve Palsy
- 52. Causes of a Third Cranial Nerve Palsy • Aneurysm - Posterior communicating - Cavernous carotid - Basilar • Microvascular • Parasellar neoplasm • …..
- 53. Third Cranial Nerve Palsy • 10-56% of isolated non-traumatic III CN palsies are due to Pcom or basilar artery aneurysms • Issues: – Aneurysm rupture - risk of death or severe disability – Recovery of palsy - early treatment is associated with better chance of recovery
- 54. Aneurysm Rupture • 40% die within the first 24 hours • Further 25% die from complications within 6 months • Remainder often have permanent neurological disability • III cranial palsy indicates that the aneurysm has expanded and may rupture within hours
- 55. III CN Palsy due to Aneurysm • Age range - children to elderly • Any combination of external and internal paresis except isolated ptosis and isolated dilated pupil • Pain does not discriminate between III CN palsies due to aneurysms from those due to ischaemia
- 56. Complete Third Cranial Nerve Palsy
- 57. Partial Third Cranial Nerve Palsy
- 58. Third Cranial Nerve Palsy: Management • Immediate imaging – CTA – MRA – Reported by an experienced radiologist
- 59. Third Cranial Nerve Palsy: First Contact • There are many serious causes of double vision • The first priority is to diagnose/rule out a third cranial nerve palsy because of the risk of death due to an underlying aneurysm • Therefore, in A&E, prioritise all cases of binocular double vision
- 60. Pupil Pathway: unequal pupils • Horner’s syndrome
- 61. Iris Muscles Sphincter Pupillae Dilator Pupillae
- 62. Causes of Anisocoria • Physiological • Sympathetic denervation – Horner’s syndrome • Parasympathetic denervation – III cranial nerve palsy – Adie’s pupil • Local ocular disease • Pharmacological
- 63. Anisocoria - History • How was the anisocoria first noticed? – Associated with ophthalmological or neurological symptoms – Incidental finding • Duration • Associated symptoms – Ptosis – Double vision – Loss of vision – Headache – Numbness – Weakness
- 64. Anisocoria - History • Past ophthalmic history – Trauma – Surgery • Past medical history – Neck trauma (surgery) – Cancer • Medications • Occupation • Systems review
- 65. Anisocoria - Examination 1. Measure anisocoria in bright and dim light 2. Assess pupil light and near responses 3. Examine the iris and pupil on a slit lamp 4. Look for associated signs – Ptosis – Eye movements
- 66. Anisocoria Abnormal Reaction to light Normal Physiological Horner’s Ocular examination Normal Abnormal III CN palsy Drugs Adie’s Ocular
- 67. Physiological Anisocoria • 20% of population • <0.5 mm • Same in all illumination • Varies / reverses with time
- 69. Horner’s Syndrome • Miosis • Ansiocoria increases in dark • Pupil redilation lag • 1 to 2 mm ptosis • Elevation of lower lid • Heterochromia if congenital / long duration
- 70. Horner’s Syndrome - Aetiology • First neurone - CVA - Demyelinating disease • Second neurone - Neoplasia - Trauma • Third neurone - Internal carotid artery disease* - Basal skull tumours
- 71. Horner’s Syndrome: Apraclonidine • Apraclonidine 0.5 -1% – Alpha-2 Adrenergic agonist with weak alpha-1 agonist activity – Dilates Horner’s pupil and reduces ptosis – attributed to denervation hypersensitivity (pre- & post-ganglionic) – May not dilate recent onset Horner’s – (not to be used in young children – risk of extreme drowsiness/unresponsiveness)
- 72. Horner’s Syndrome - Investigation • MRI head to upper thorax with contrast • (urinary catecholamine – neuroblastoma in children)
- 73. Horner’s Syndrome: First Contact • Patients with recent onset (days) of anisocoria, with an ipsilateral ptosis (+/- ipsilateral facial pain) should be assessed urgently for possible carotid artery dissection.