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CP2 Ophthalmology > Neuro-Ophthalmology > Flashcards

Neuro-Ophthalmology Flashcards

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1
Q

Describe the appearance of the disc margin in optic disc swelling

A

Disc margin is ill defined with haemorrhages at the edges - the disc itself remains pink and the cup is not enlarged, but can be hard to see

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2
Q

What are the differentials of an optic disc swelling?

A

Optic neuritis
Papilloedema (has to be bilateral)
Malignant hypertension
Arteritic anterior ischaemic optic neuropathy
Non-arteritic anterior ischaemic optic neuropathy

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3
Q

Describe the appearance of the optic disc in optic neuritis?

A

Swollen disc - margin is blurred with a pink colour and a normal cup

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4
Q

What does the patient complain of in optic neuritis?

A

Blurring of vision and a dull ache, especially on eye movement

Colour vision: red gone slightly

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5
Q

Optic neuritis - examination findings?

A
  1. Reduced central vision, para-central scotoma or enlarged blind spot
  2. RAPD
  3. desaturation of red colour vision
  4. Transient neurological symptoms: increase in blurring with exercise, tingling sensation in the fingers or toes
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6
Q

What is papilloedema?

A

Swelling of the optic discs due to increased intra-cranial pressure
(bilateral)

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7
Q

In what circumstance could papilloedema be unilateral?

A

Patient has developed optic atrophy in one eye previously - patient will complain of transient blurring of vision and may also have headaches.

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8
Q

What are the retinal / eye signs of papilloedema?

A

Splinter haemorrhages
Exudates
Cotton wool spots
Retinal folds

Also enlarged blind spots (early) and a gradual progressive field loss (late) - generalised constriction

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9
Q

What is Arteritic Anterior ischaemic optic neuropathy?

A

Inflammation of the arteries to the optic disc which causes infarction

(temporal arteritis)

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10
Q

Which arteries get inflamed in AION?

A

temporal arteries - cause occlusion of the vascular supply to the optic nerve and hence it gets infarcted

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11
Q

What symptoms does the patient experience in AION?

A

Before it happens - temporal headache, jaw claudication (due to jaw ischaemia) and scalp tenderness on the affected side

Patient may lose weight and will have aches all over the body
Visual loss caused by an inflammatory infarction of the posterior ciliary artery: ESR and CRP are significantly raised

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12
Q

What is the management of AION?

A

Urgent high dose steroid (1-1.5mg per kg, usually 80mg)

temporal biopsy to give a conclusive diagnosis (giant cells)

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13
Q

What is the appearance of AION on fundoscopy?

A

Pale/white and margins are blurred

Cup is obliterated and will not be seen - rest of the fundus may also have some pallor

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14
Q

What is Non arteritis anterior ischaemic optic neuropathy caused by?

A

Swollen artery, usually due to atherosclerosis.
This causes obliteration of the lumen of the posterior ciliary arteries and the optic nerve gets infarcted (top or bottom)

(central retinal artery occlusion)

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15
Q

Is ESR raised in non-arteritis

A

no - non inflammatory

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16
Q

What is the treatment of non-arteritis ischaemic optic neuropathy

A

low dose aspirin

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17
Q

What is optic atrophy?

A

means the optic nerve is atrophic and pale

There is loss of the surface capillaries of the optic disc and associated RAPD

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18
Q

What is the cause of optic atrophy?

A

Anything that causes a disruption of the blood supply to the optic nerve, or compression of it

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19
Q

Which muscles are controlled by cranial nerve 3?

A

Superior rectus
Medial rectus
Inferior rectus
Inferior Oblique

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20
Q

What muscle is controlled by cranial nerve IV?

A

Superior oblique

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21
Q

What muscle is controlled by CNVI?

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A

Lateral rectus

22
Q

What muscles are affected by third nerve palsy?

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A 
SR
MR 
IR
IO 
levator palp superiors and intraocular pupil muscles
23
Q

What is the clinical presentation of third nerve palsy?

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A

Down and out (SO and LR are spared)
Ptosis
Dilated pupil (efferent defect) but no APD

24
Q

What muscle is affected by fourth nerve palsy?

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A

Superior oblique

25
What is the clinical presentation of fourth nerve palsy
Eye unable to look down and in on affects side | vertical diplopia is most marked on looking down and in: stairs or reading
26
What nerve is affected in sixth nerve palsy?
Lateral rectus
27
What is the clinical presentation of sixth nerve palsy?
Inability to abduct the affected eye - may drift to the medial side
28
What does the seventh CN supply?
MM of facial expression - and mm that close the eye
29
What is the clinical presentation of CNVII palsy?
affected eye cannot be closed - tear coverage will be reduced Dry cornea and exposure keratitis
30
What is Bell's phenomenon?
Eyeballs roll up when the eyes are closed to protect the cornea
31
Describe some common pupil problems?
``` RAPD/APD Adie's pupil Argyll Robertson pupil CN II palsy Horner's syndrome Light-near dissociation ```
32
Describe the path of light in the pupils
1. Light stimulates the retinal ganglion cells after reaching the light receptors 2. This goes to the pre-tactile nucleus and then signals are sent to teh Edinger-Westphal nucleus on the same and contralateral side
33
What is the cause of APD?
Disruption of fibres travelling from the RGC to PTN and from PTN to the same and contralateral sided EWN.
34
Where does the afferent pupil go to?
From the retina up to the EWN
35
What is RAPD?
Similar to APD but is not complete, so a minimal response will be noticed. Swinging torch test will show maximal constriction in both eyes when shined on the good eye, and a slight dilation in both eyes when shined on bad eye
36
If you have APD, what will pupil examination reveal?
No consensual or direct response
37
If you have RAPD, what will pupil examination reveal?
reduced light and consensual response Pupil dilates on the swinging light test
38
Describe the path of the efferent pathway?
Starts from the EWN and includes the inferior division of the third nerve, pupil and ciliary body.
39
What is the problem in Horner's syndrome?
Lesion affecting the sympathetic supply to the eyes Compression of the sympathetic chain
40
Horner's syndrome clinical presentation?
PTOSIS + MIOSIS + anhydrosis Affected pupil is smaller than normal Some ptosis Pupil inequality is more pronounced in the dark Patient may have a neck scar - pathology to the sympathetic chain, partial ptosis and eyes may appear sunken in Pancoast tumour
41
What is the cause of Argyll Robertson pupils?
Tertiary syphilis (neurosyphilis affecting the midbrain)
42
What is the appearance of the pupils in Argyll Robertson's pupils?
'Accomodate but don't react' Pupils = small and irregular (both affected and maybe asymmetry between the two) - sluggish response to light Light-near dissociation Patient may be blind from optic atrophy
43
What is light near dissociation?
A negative reaction to LIGHT but a positive reaction to accommodation
44
What is the cause of light near dissociation?
Brainstem pathology
45
How does light near dissociation come about?
When the fibres leave the EWN and enter the inferior division, they enter the ciliary ganglion. This is responsible for pupil constriction and for the ciliaris muscle which contracts, releasing tension of the zonular fibres (accommodation)
46
What is Adie's pupil?
A unilateral dilated pupil in an otherwise healthy patient
47
Who does Adie's pupil tend to occur in?
young women
48
What is the presentation of Adie's pupil?
unilateral dilated pupil in otherwise healthy patient poor pupil response to light slow response to accommodation
49
What is Adie's pupil thought to be due to?
viral/bacterial infection of ciliary ganglion and autonomic system
50
What is the cause of optic neuritis?
MS - can be the first presentation diabetes syphilis

CP2 Ophthalmology (14 decks)

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