NEURO-OPHTHALMOLOGY

Chuanbao-Li
 Introduction
• As demonstrated by their common embryological origin, the
retinas and anterior visual pathways (optic nerves, optic
chiasm, and optic tracts) are an integral part of the brain,
providing a substantial proportion of total sensory input.
• They frequently give important diagnostic clues to central
nervous system disorders.
• Intracranial disease frequently causes visual disturbances
because of destruction of or pressure upon some portion of the
optic pathways.
• Cranial nerves III, IV, and VI, which control ocular
movements, may be involved, and nerves V and VII are also
intimately associated with ocular function.
 Clinical Examination
• Visual Acuity
• Colour Vision
• Visual Fields
• Pupils
Normal Optic Disc
Cupped disc
 The swollen optic disc

•Papilloedema
•Papillitis
•Malignant hypertension
•Ischaemic optic neuropathy
•Diabetic optic neuropathy
•CRVO
•Intraocular inflammation
The pale optic disc
Congenital
Secondary to
raised IOP
vascular
retinal disease
optic
neuritis
optic nerve
compression
trauma
Glaucoma
 Ocular motility
abnormalities
• Third nerve palsy • Sixth nerve palsy
– Double vision – Double vision
– Eye turned down & out – Eye turned in
– Ptosis
– Dilated pupil &
headache
 Localising the lesion
shows the types of field defects caused
by lesions in various locations of
the pathway.
• Lesions anterior to the chiasm (of
the retina or optic nerve) cause
unilateral field defects;
• lesions anywhere in the visual
pathway posterior to the chiasm
cause contralateral homonymous
defects.
• Chiasmal lesions usually cause
bitemporal defects.

visual pathway
Optic Neuritis

swollen optic disc

 Optic Neuritis
Symptoms
• Loss of vision deteriorating over hours (rarely) to days
(most commonly), with the nadir approximately 1 week
after onset.
• Visual loss may be subtle or profound. Usually unilateral,
but may be bilateral.
• Age typically 18 to 45 years. Orbital pain, especially with
eye movement.
• Acquired loss of color vision. Reduced perception of light
intensity.
• RAPD(Relative afferent pupillary defect )
 Optic Neuritis

RAPD(Relative afferent pupillary defect )

 Optic Neuritis
Etiology
• Idiopathic.
• MS(multiple sclerosis) : Frequently optic
neuritis is the initial manifestation of MS.
• Childhood infections or vaccinations.
• Other viral infections: e.g., herpes zoster.
• Contiguous inflammation of the orbit
 Optic Neuritis
Treatment
If patient seen acutely with no prior history of MS or optic
neuritis:
• If MRI reveals at least one typical area of demyelination, offer
pulsed intravenous injection steroid in the following regimen
within 14 days of decreased vision
—Methylprednisolone 1 g/day i.v. for 3 days, then
—Prednisone 1 mg/kg/day p.o. for 11 days, then
—Taper prednisone over 4 days (20 mg on day 1, 10 mg on days
2 and 4).
—Antiulcer medication (e.g., ranitidine 150 mg p.o., b.i.d.) for
gastric prophylaxis.
 Optic Neuritis
Treatment
• If MRI shows two or more characteristic
demyelinating lesions, treat with the
aforementioned steroid regimen. Refer to
neurologist for possible treatment
• With a negative MRI, the risk of MS is low
In a patient with diagnosis of prior MS or optic
neuritis:
• Observation.
 Optic Neuritis
Note

• NEVER use oral prednisone as a primary

treatment because of increased risk of
recurrence.