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Flashcards in Ophthalmology Deck (18):
1

Visual field defects: Parietal lobe tumour

A parietal lobe tumour is associated with disturbed sensation including localisation of touch and disturbed two point discrimination. The typical associated visual field defect is a lower homonymous quadrantanopia and it affects the upper fibres of the optic radiation. This is the classical lesion and tumours of the temporal lobe tend to produce superior homomomous quadrantanopia. However,very large tumours can produce homonymous hemianopia.

2

Visual field defects: Bilateral occipital lobe infarction

Bilateral occipital infarction results in cortical blindness where the brain is unable to process the light signals it receives from the retina and optic nerves.

3

Visual field defects: Central retinal artery occlusion

A central retinal artery occlusion would typically result in sudden uniocular blindness. Causes of central retinal artery occlusion include emboli (carotid stenosis, AF) and giant cell arteritis.

4

Fracture of the floor of the orbit

There is a fracture of the floor of the right orbit with haemorrhage in the associated maxilla.

An important clinical feature is whether there is any diplopia (the usual reason for requiring a CT scan).

A CT is performed to assess whether the rectus muscle is trapped by the fracture necessitating surgery.

5

A 68-year-old female patient is seen on the ward.
She complains of severe pain in her right eye. There is blurring of vision and she feels nauseated and has vomited several times.
Earlier in the day she has undergone colonoscopy for evaluation of her longstanding Crohn's disease. The endoscopist has made a comment that the examination was difficult.
What is the likely cause of her painful red eye?

Acute angle closure glaucoma

Anticholinergic agents are sometimes used during endoscopy to cause smooth muscle relaxation to aid examination when difficulty is encountered.

These agents cause pupillary dilatation thus precipitating acute angle closure glaucoma in susceptible patients.

In patients with a history of glaucoma, glucagon is used instead of anticholinergics.

6

Orbital emphysema

The diagnosis is of orbital and subcutaneous emphysema. This is the black tracks of air seen related to the temporal muscles, and in the orbits. There should normally be no air in relations to these structures. The patient had been assaulted and the appearances relate to associated fractures of the sinuses.

7

Third nerve palsy

In a third nerve palsy there is typically ptosis with a dilated, unreactive pupil and the eyeball is displaced downwards and outwards.

Enophthalmos is seen in Horner's syndrome. There would be a dilated not constricted pupil and a divergent squint - affected eye deviated 'down and out'.

Increased lacrimation may be seen in VIIth nerve palsy.

8

Pancoast tumour

Horners syndrome
Pancoast's tumour of the lung, (apical tumour) is associated with infiltration of the lower fibres of the brachial plexus (wasting and weakness of the small muscles of the hand and C8, T1 sensory loss) together with infiltration of the sympathetic nerve fibres producing ptosis, miosis (small pupil) and loss of sweating on that side of the face. Other causes of Horner's syndrome include cervical rib, lateral medullary syndrome and syringomyelia.

9

Graves disease

Chemosis
Graves' ophthalmopathy is associated with chemosis, conjunctival oedema, exophthalmos and proptosis. The condition is associated with TSH receptor antibodies that cross react with antigens within the orbital fat cells.

10

Familial hypercholesterolaemia

Corneal arcus
Familial hypercholesterolaemia, an autosomal recessive condition, is associated with elevated cholesterol concentrations due to reduced hepatic LDL receptors. The condition is associated with premature coronary artery disease and is manifest by tendon zanthomas, xanthelasma and corneal arcus.

11

A 38-year-old female presents with sudden loss of vision but fundoscopy is normal. She had a similar episode about one year back, which resolved completely within three months. On examination, she has mild weakness of right upper limb and the reflexes are exaggerated.

Periodic visual loss in a young female suggests relapsing and remitting multiple sclerosis presenting as optic neuritis. Of patients with multiple sclerosis, 15-20% initially present with an episode of optic neuritis and approximately 70% have an optic neuritis episode at some point during the illness.

Flashes of light and sudden loss of vision suggest retinal detachment which is more common in myopic patients. There is usually no pain associated with retinal detachment. Extremely nearsighted (myopic) subjects have longer eyeballs with thinner retinas that are more prone to detaching. Scleral buckling bends the wall of the eye to meet the hole in the retina.

12

A 54-year-old male with myopia develops flashes of light, floaters preceding loss of vision.

These symptoms of floaters and flashes of light preceding visual loss suggest retinal detachment. Surgical treatment is often required

13

A 65-year-old female presents with headache and loss of vision. Her ESR is markedly elevated.

The third patient presents with giant cell arteritis (GCA), and should be treated with high dose steroids. When GCA involves the arteries that supply blood to the eyes, blindness in one or both eyes may develop suddenly. Strokes may rarely occur.

Some of the more common symptoms in GCA include headaches, pain in the jaw or tongue muscles when eating or talking, and tenderness of the scalp over the temples. GCA and polymyalgia rheumatica (PMR) seem to be related, as they often occur together. Over 10 % of people with PMR also have GCA; approximately 50 % of people with GCA also have PMR.

14

A 55-year-old male hypertensive suddenly lost his vision. The retina is pale and the fovea appears as a bright cherry red spot.

Pressure over eyeball
This is central retinal artery occlusion and occasionally pressure over the eyeball or aspiration of vitreous may be effective in dislodging the clot.

The fourth patient is older and has hypertension, and sudden loss of vision with a pale disc and a cherry red spot suggests central retinal artery occlusion. photo.

15

A 55-year-old man presents with mild headache. He has changed his spectacles thrice in one year. There is mild cupping present in the disc and sickle shaped scotoma present in both eyes.

Pilocarpine eyedrops
Pilocarpine, a drug that promotes pupillary constriction, miotic, is a treatment for glaucoma.

In chronic simple glaucoma a sickle-shaped scotoma called Seidel's sign may be seen as a significant field defect. Pilocarpine 1 - 4% is a direct cholinergic agonist which will cause miosis and accommodative spasm. It is used to reverse the action of mydriatics but its greatest therapeutic use is in lowering ocular pressure in both acute and chronic glaucoma by acting through the ciliary muscle to increase aqueous outflow.

Pilocarpine may cause parasympathetic actions, for example, salivation, sweating, hypertension, tachycardia, diarrhoea and vomiting, and pulmonary oedema. Ciliary spasm may cause browache which may be more severe in the initial two to four weeks of treatment.

16

Horners

Horner's syndrome results from interruption of the sympathetic innervation to the head. It was originally described with cervical lesions causing damage to the T1 contribution to the cervical sympathetic chain, but may be due to lesions anywhere along the sympathetic pathway.

The features of Horner's include

Partial ptosis
Myosis (contraction)
Apparent enophthalmos
Lack of sweating
Nasal stuffiness on the affected side.
Myosis occurs due to paralysis of the dilator pupillae and ptosis is due to paralysis of the sympathetic muscle fibres transmitted via the oculomotor nerve to the upper eyelid.

Horner's may follow

Operations on, or injuries to, the neck in which the cervical sympathetic chain is damaged
Malignant invasion from lymph nodes or adjacent tumour
Spinal cord lesions at the T1 segment.

17

interruption of the sympathetic nerve supply in the eye

Miosis

In the eye stimulation of the parasympathetic nervous system results in constriction of the pupil (miosis), stimulation of the sympathetic nervous system results in dilatation of the pupil (mydriasis).

Thus interrupting the sympathetic causes miosis.

Balance between the parasympathetic and sympathetic nervous systems controls the pupil size. Contraction of the superior and inferior recti and obliques results in a degree of wheel movement or torsion of the orbit. This can be either clockwise (intorsion) or anticlockwise (extorsion) and is controlled by the somatic motor part of the oculomotor nerve.

Myopia (nearsighted) results when the eye and lens refract light too much. Most refraction of light occurs at the cornea. The lens is focused for near vision by the ciliary muscle and is supplied by parasympathetic fibres from the oculomotor nerve. The ciliary muscle has no opponent as the lens relies on elastic recoil.

18

Oculomotor nerve

The oculomotor (IIIrd) nerve passes anteriorly through the superior orbital fissure into the orbital cavity forming a superior and inferior division.

The superior division supplies the superior rectus and the levator palpebrae superioris while the inferior division gives branches to the inferior rectus, inferior oblique, medial rectus and the ciliary ganglion.

The abducens (VIth) nerve supplies the lateral rectus.