NEURO-OPHTHALMIC PEARLS Neuro “Pearls”

13 Pages·2012·7.92 MB·English

N-O Emergencies
Pearls:Important Diagnosis
NEURO-OPHTHALMIC
PEARLS Severe consequences:
• Irreversible damage to the patient
*Potentially treatable
* Early Dx & management critical
ROSA ANA TANG, MD,MPH,MBA Medico legal implications
MS EYE CARE-UHCO-2011 * Early intervention saves lives.
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PPiittuuiittaarryy aappoopplleexxyy:: ppeerrmmaanneennttllyy bblliinndd iiff
1) Acute diplopia nnoo iinntteerrvveennttiioonn
Acute painful ophthalmoplegia CCoommpprreessssiivvee ooppttiicc nneeuurrooppaatthhiieess:: mmoossttllyy
[more anxious if pupil abnormal] iiff dduuee ttoo ppiittuuiittaarryy ttuummoorrss aass rreevveerrssiibbiilliittyy iiss
2) Acute visual loss[especially if disc is ttiieedd ttoo cchhrroonniicciittyy
normal]-check that pupil for RAPD
MMyyaasstthheenniiaa // tthhyyrrooiidd ddiissoorrddeerrss::
Is it optic neuritis or CRAO??
3)Visual field defects [BTHand acute] dduuee ttoo tthheeiirr ssyysstteemmiicc aassssoocciiaattiioonnss aanndd
4)Painful anisocoria [dissection] hheeaalltthh rreellaatteedd iissssuueess [[tthhyyrrooiidd ssttoorrmm aanndd
5)Numbness[with or without pain] mmyyaasstthheenniicc ccrriissiiss]]
Neuro “Pearls” to keep PPeeaarrll::TTOOPP TTEENN DDIIAAGGNNOOSSEESS
you out of trouble YYOOUU DDOONN’’TT WWAANNTT TTOO MMIISSSS
Beware of the silent Neuro-ophthalmic
patient : 1) Acute diplopia
Acute painful ophthalmoplegia
patients with brain tumors can be
[more anxious if pupil abnormal]
sometimes hidden behind a diagnosis of 2) Acute visual loss[especially if disc is
glaucoma–sp. low tension glaucoma. normal]-check that pupil for RAPD
Is it optic neuritis or CRAO??
3)Visual field defects [BTHand acute]
4)Painful anisocoria [dissection]
5)Numbness[with or without pain]
Pearl: TOP TEN DIAGNOSES Pearl:TOP TEN DIAGNOSES
YOU DON’T WANT TO MISS YOU DON’T WANT TO MISS
6)Pituitary apoplexy: permanently blind if no 9.GCA
intervention
10.PAPILLEDEMA
7)Progressive visual loss: Compressive optic
neuropathies: mostly if due to pituitary tumors
as reversibility is tied to chronicity
8)Myasthenia:
due to their systemic associations and health
related issues [ myasthenic crisis]
NNeeuurroo ssyymmppttoommss tthhaatt Three sx that may cause
mmaakkee uuss PPAANNIICC us to PANIC too!!!
3)Visual field defects [BTHand acute]
1. Acute diplopia: can be a killer
4)Painful anisocoria [dissection]
[ie: aneurysm/myasthenia]-always make
sure what the underlying cause is 5)Numbness[with or without pain]
2.Papilledema: the cause can kill the
patient
SIGN: PUPIL
ABORMALITY :
Anisocoria
P =pupil abnormality
In a patient with a
Anisocoria Unilateral fixed dilated
pupil :
LOOK FOR :
Normal light reaction Abnormal light
reaction ANY HINT OF III CN PARESIS OR
PTOSIS.
•physiologic •Adie’s tonic
LIGHT-NEAR DISSOCIATION OF
•Horner’s •3rd nerve palsy
PUPIL : TONIC PUPIL
•pharmacologic
EVIDENCE OF ANT. SEGMENT
•sphincter TRAUMA IN SLIT LAMP EXAM.
damage
Dilation lag:
Question : In light
Anisocoria w/ dilation lag
what if there is greater
anisocoria in dark
In dark in 1st 5 seconds
P= pupil abnormality
In Dark after 15-20 seconds
How to localize the
Localization of the lesion
lesion in Horner’s according to the symptoms in
syndrome Horner’s Syndrome
First-order neuron Second-order neuron Third-order neuron
lesions lesions lesions
Historical : based on associated
Hemisensory loss Preceded by trauma Include diplopia from sixth
symptoms. Dysarthria Facial, neck, axillary, shoulder or nerve palsy
Dysphagia arm pain Numbness in the distribution
Clinical: Based on associated signs. Ataxia Cough of the first or second division of
Vertigo Hemoptysis the trigeminal nerve
Based on pharmacological testing. Nystagmus History of thoracic or neck surgery Pain.
History of chest tube or central
venous catheter placement
Neck swelling.
HISTORICAL DIAGNOSIS OF HORNER’S
Pharmacological :How to confirm
Horner’s Horner’s syndrome-Cocaine
testing
Etiology Syndromes: Cocaineblocks the re-uptake of the
neurotransmitter Norepinephrine in pre-
50% idiopathic Lateral medullary or
synaptic terminalcausing dilationof the
50% secondary Wallenberg: central normal pupil
Cavernous sinus:
InHorner’s:no dilationof the tested pupil is
post-ganglionic seen with cocaine. This is due to lack of Nor-
+VI CN ipsilateral epinephrine molecules on the pre-synaptic
vesicle : there is nothing to block .
Tells usTHERE IS A Horner’s but not the
level of the lesion.
Apraclonidine (0.5% or 1%)
APRACLONIDINE 0.5 %
Iopidine
(cid:61548)Apraclonidine is an ocular hypotensive Should eliminate or reverse the
agent. anisocoria [small Horner’s pupil
becomes larger and normal stays same
(cid:61548)It is a weak,direct-acting alpha-1 receptor
agonist. size].
(cid:61548)Apraclonidine has little to no effect on a normal Reverses the ptosis.
pupil size.
Read after 30 minutes of instillation.
Where is the Horner’s lesion- - Where is the Horner’s lesion- -
Paredrine (Hydroxyamphetamine) Test Paredrine (Hydroxyamphetamine) Test
1. Hydroxyamphetamine releases 3.First and second order neuron
norepinephrine from the stores in dysfunction-no effect of Paredrine
the post-ganglionic neuron causing as this substance only works at the
dilation of the pupil. level of the third order(post-
ganglionic neuron) hence pupil
DILATES with paredrine as the
normal pupil does.
Congenital Horner’s
Syndrome
Heterochromia with LIGHTER IRIS in Horner’s
eyemost distinct feature Question: acute painful
(cid:61548) Normal pigmentation of iris depends on the sympathetic
innervation and occurs before age 2 Horner’s
(cid:61548) So usually in Horner’s before age 2 you see heterochromia
(cid:61548) Think of birth trauma to pre-ganglionic neuron (forceps).
P=pupil abnormality
Etiology of Post ganglionic
SIGN: PUPIL
Horner’s
1. Internal carotid A. dissection-Acute MOST IMPORTANT OBJECTIVE
Unilateral headache or facial pain. PUPIL SIGN IN UNILATERAL VISUAL
2.Cluster headache-Transient post- LOSS CASES
ganglionic Horner’s syndrome with
episodes of excruciating hemicranial
headaches.
3.Trauma-base of skull fractures
4. Cavernous sinus Lesion
SIGN: DISC EDEMA
IF BILATERAL: MUST EXCLUDE
SIGN : corneal
PAPILLEDEMA
anesthesia
In the absence of corneal disease
What does this means?
Increased ICP
Swollen optic nerves Increased Intracranial Pressure with
abnormal Imaging and/or CSF (other
than high pressure)
Bilateral ON swelling is likely due to
MOVIE pneumonic:to be excluded
increased ICP
FIRST!!!!!!!!!!!!while monitoring
First investigation should be imaging
VA/fields
with brain MRI to exclude brain tumor
(cid:61548)M Mass/Meningitis
(cid:61548)O Obstructive Hydrocephalus
(cid:61548)V Venous Hypertension
(cid:61548)I Infectious Causes
(Abscess/Meningitis) ©NEDS2001
(cid:61548)E Edema (Non Infectious meningeal )
Modified Dandy criteria of IIH
Pearl
Ref: Friedman &Jacobson : Neurology :59:1492-1495,2002
Symptoms and signs of
The diagnosis of pseudotumor cerebri increased ICP
is a diagnosis of exclusion This is based Otherwise normal
neurologic exam
on a specific diagnostic criteria as
Normal level of alertness
follows:
Neurodiagnostic normal
Hx: no sx other than HA, tinnitus ,dv,tvo. except elevated ICP
Exam :disc swelling normal BP No other cause of
increased ICP present.
Normal MRI and CSF except for high
pressure
Japanese Pearl!! Secondary Pseudotumor
BILATERAL DISC EDEMA syndromes
ALWAYS CHECK THE BLOOD All imaging negative, including
PRESSURE AS MALIGNANT
MRI, MRA, MRV, Angiogram,
HYPERTENSION CAN PRESENT
CAT scan
WITH THIS FUNDUS PICTURE
Looks like primary pseudotumor
cerebri but there is something
else that may be precipitating it.
SIGN: DISC EDEMA-WHAT ABOUT
Typical Patient:- PTC
THIS PICTURE?
Clinical Associations
Obesity
Obese female of childbearing Recent weight gain
age
General population: Pregnancy?
1 : 100,000
Women 20-44 who are 20%
greater ideal body weight:
19.3 : 100,000
Female : Male
8 : 1
ODEMS type I NEURORETINITIS ODEMS -ATYPICAL
UNI OR BILATERAL
Vascular entities
TYPICAL: Associated to infections AION: rare
Viral
Papilledema-CHRONIC
Syphilis
Malignant Hypertension: bilateral
Cat Scratch
Lyme’s
TB
Toxoplasma /Toxocara
Idiopathic
Pearls
Pearl
True ODEMS is idiopathic, often with
optic disc edema as the presenting
(cid:61548)Every new patient c/o blurry vision and
sign & 2 weeks later the star follows
you cannot correct to 20/20 OR you find
elevated discs should have at least
ODEMS IS NOT SEEN IN MS confrontation VF & pupil check for RAPD
PATIENTS. (cid:61548)Automated perimetry for those who have
lots of Sx and no findings.
Neuroretinitiswith specific etiologies
should be treated appropriately
SIGN: PROPTOSIS TRIO TYPE I
MOST COMMON CAUSE UNI OR Occurs most often in women.
BILATERAL : THYROID Symmetric proptosis.
IN CHILDREN–UNILATERAL AND Symmetric eyelid retraction.
ACUTE-THINK ORBITAL CELLULITIS
Minimal orbital inflammation.
Minimal or no myopathy, however
IF PULSATILE TINNITUS/BRUIT– EOMS may be large due to edema not
THINK CCF myositis.
Corneal exposure may be considerable.
Clinical Presentations-
TRIO TYPE II
Thyroid
EOM enlargement marked /asymmetric
withmyositisand restrictive myopathy : (cid:61550)Mild orbitopathy
IR & MR most common involved :“can’t
look up“. (IR>MR>SR>LR)
(cid:61550)Moderate orbitopathy
With restrictive myopathy the eye is
pulled in the direction of the involved
muscle. (cid:61550)Optic neuropathy
Goals of Treatment-
TRIO-TREATMENT
Thyroid
Protection of visual acuity Localized protective/lubrication.
Control of inflammation Medical anti-inflammatory: high dose
( 80-100 of prednisone QD) for few weeks.
Correction of muscle dysfunction
Medical: orbital radiation is preferred for
Reduction of proptosis patients over age 55 (Ref: Martin &Corbett ).
Improvement in cosmetic appearance Surgical for visual loss:orbital
decompression if medical treatment fails.
Surgical for motility/lid: only when
orbital findings stabilize.
Radiotherapy: less and less likely to be of
any help
Pituitary tumors and the
optometrist PITUITARY GLAND TUMOR–CLINICAL
PRESENTATION
Pituitary tumors in adults present a wide spectrum of symptoms and
physical findings many of which affect vision. Hormone Mass effect
Visual symptoms are gradual in onset due to the benign histopathology
of these tumors and its location. (cid:61623) Galactorrhea/
Amenorrhea (cid:61623) Neuro-ophthalmologic ( vision
(cid:61623) Acromegaly loss, diplopia)
(cid:61623) Cushing’s (cid:61623) Cerebrospinal fluid (CSF) leak
(cid:61623) Hypopituitarism
Pituitary tumor
In pituitary disorders
treatment
Goals of pituitary tumor treatment :
Routine visual field examinations after
control of tumor growth
treatment:
(cid:61548)1styear(cid:61664)every 3 months
normalize pituitary function (cid:61548)2ndto 5th year(cid:61664)every year
(cid:61548)Every 2 years there after
Savino et al
preservation or restoration of visual
function.
PITUITARY APOPLEXY
Sign: PTOSIS
TRIAD
SEVERE HEADACHE WITH SX OF 1.Isolated ptosis with no DV and normal
SAH pupils is SELDOM an emergency
ACUTE DIPLOPIA : III OR VI BUT Ocular myopathy [MG] rarely presents
TOTAL OPHTHALMOPLEGIA MOST emergently if there is only ptosis unless
LIKELY can’t swallow or breath-then we are in
VISION LOSS /BTH trouble.
Purely Ocular
Laboratory tests in MG
Myasthenia
Initial presentation of MG in up to Anti-acetylcholine receptor binding
70% antibodies should be measured
Ocular precedes clinically generalized Positive in 50 % of Ocular MG and 90%
MG in 50-70 % of patients. of Systemic ( Generalized MG)
(cid:61548)Usually generalizes within 2 years of
onset of ocular symptoms
M.G.-Management
Less common
antibody:MUSK (cid:61548)-Adjustments
(cid:61548)Change medications that can
Seen inAch Receptor Ab negative
exacerbate or cause
myasthenia.
(cid:61548)Education (rest, pacing, diet,
Can be seen with ocular myasthenia but
temperature, stress)
rarely.
(cid:61548)For ocular (ptosis crutches,
Worse prognosis in regards to systemic
prisms, patching)
symptoms.
SIGN: PTOSIS Acute double vision
<2 mm: Horner’s-tip: look for brother’s Beware of calling decompensated
kiss sign [narrow fissure] and miosis strabismus any case that presents with
>2 mm: acute diplopia and no clear cut CN
paresis.
Mechanical: isolated [lev dehiscence]
Myopathic: variability= MG
Diplopia: look for IIIrd CNP