6.1.14 Assesses signs and symptoms of neurological significance. Flashcards
General symptom of neurological condition
- Reduced vision / transient loss of vision
- Headache
- Loss of VF
- Pupil abnormality
- Diplopia
- Dyschromatopsia - mainly R/G, so test Isihara monocularly
- Diminished light brightness sensitivity , desaturated red can combine this aspect & red green deficiency
Tests to do for neurological:
- History & symptoms – headaches, visual symptoms, sudden loss of vision
- VA
- Pupils
- Motility / CT
- Stereoacuity?
- Fundus exam
- Including spontaneous venous pulsation test
- VF test
- Amsler
- Colour vision
- Check for red desaturation
- City to include tritan
- Contrast sensitivity
Optic nerve dysfunction, expect:
- Reduced VA – D&N
- Impaired CV – R/G or B/Y
- RAPD
- VF defect
- Impaired CS
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Differential diagnosis of raised optic disc
Optic disc oedema
* Papilloedema
* Anterior ischemic optic neuropathy
* Optic neuritis
Compression of optic nerve
* Infiltration of the optic nerve
* Congenital optic neuropathies
* Toxic optic neuropathies
* Traumatic optic neuropathies
(Raised but no swelling)
* Optic disc drusen
* Tilted optic disc
* Myelinated nerve fibres
* Hypermetropic crowded disc
Intraocular disease which can cause raised disc appearance
* CRVO, posterior uveitis, posterior scleritis, hypotony
Excavated disc anomalies
* Optic disc pit
* Coloboma
* Optic nerve hypoplasia
* Morning glory anomaly
Optic disc oedema
Characteristic appearance of the optic nerve head:
- Elevated appearance of nerve head
- Filling of cup
- Retinal vessels drape over disc margin
- Blurring of margin
- RNFL oedema – greyish appearance that obscures vessels
- Hyperaemia – BV swollen, redness
- Retinal venous dilatation & tortuosity
- Peripapillary haemorrhages, exudates, cotton wool spots
Papilloedema
Swelling of the optic nerve head secondary to raised ICP
Causes
* Intracranial mass
* Hydrocephalus (dilation of ventricles)
* Central nervous system infection e.g. meningitis
* Trauma
* Infiltration e.g. leukaemia, sarcoidosis
* Benign intracranial hypertension (only benign when all other causes are absent) – most common in overweight, middle aged women
Papilloedema
Symptoms
- Occasionally asymptomatic (could be picked up in routine eye exam)
- Nausea and vomiting – projecticle vomiting
- Deterioration of consciousness – from slight (drowsy) to dramatic
- Pulsatile tinnitus
- Can be ‘muzzy headed’ at start and then develop into extreme pain, usually presenting at hospital within 6 weeks
- Characteristically in morning, waking up px
- Generalized or localised
- Headaches worse when pressure increases - moving head, bending over, coughing
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Papilloedema
Visual symptoms
- (only after some time i.e. in established cases)
- Visual symptoms often absent but reduced VA in later stages
- Transient visual loss (especially when bendning over)
- Horizontal diplopia (6th nerve palsy)
- Constriction of visual field
- Altered colour perception
Signs of Papilloedema
EARLY – first few weeks
* VA normal
* Optic disc shows Hyperaemia, mild elevation and indistinct margins
* Dilation of capillary net
* Absent SVP (absent in 20% normals)
ESTBALISHED ~ 6 months
* VA normal or reduced
* Optic disc shows venous engorgement, moderate elevation, flame-shaped haemorrhages and cotton wool spots
* Enlarged blind spot
* Hard exudates in macular fan
CHRONIC > 6 months
* VA is variable
* Optic discs are pale and markedly elevated
* No haemorrhages or cotton wool spots
* Collateral vessels form
* Variable field loss
ATROPHIC – years after initial presentation
* VA severely impaired
* Fields impaired
* Optic discs are pale grey and slightly elevated with indistinct margins
papilloedema
OCT
- RNFL white showing raised
- Can use measurement tools on OCT to measure disc swelling (>400 microns indicate a swollen disc)
papilloedema
Management (CMGS)
- Communicate severity of situation to px
- Phonecall to ARC
- Emergency referal to ophthalmology/neurology with letter in hand
- Younger px = less likely to be bengin
- Treatment of cause at HES
- Carbonic anhydrase inhibitor to reduce ICP in IIH
AION types
- **Inflammation of ON due to ischaemia **
Arteritic (AAION)
* Occurs in >70s
* Caused by giant cell arteritis
* Associated systemic features e.g. hard temporal artery, scalp tenderness, jaw claudification, muscle weakness, reduced appetite
* Severe vision loss (poorer than 6/60)
* Pale swollen disc, cotton wool spots, RAPD
* Stroke risk high: high chance of 2nd eye being affected
Non-arteritic (NAION)
* Occurs in >60s
* Caused by occlusion of short posterior arteries (RF’s: DM, HBP, smoking)
* No systemic features
* Mod-severe loss of vision (better than 6/60)
* Hyperaemic swollen disc, peripapillary flame shaped haems
* Lower risk
AAION (GCA)
Risk factors
- Hypertension
- Smoking
- Diabetes
- Stroke
- Sleep apnoea
- Anaemia
AAION (GCA)
Symptoms
- Sudden, profound unilateral visual loss
- May be proceeded by transient visual obscuration (amaurosis fugax), flashing lights
- Periocular pain
- Systemic – headache, pain in the neck & temples, weight loss, fatigue, scalp tenderness, jaw claudication
AAION (GCA)
Signs
- VA HM to no PL
- Pale swollen disc
- Peripapillary haemorrhages
- Cotton wool spots (signifying retinal ischaemia)
- RAPD
AAION (GCA)
Management
- Emergency referral to ophthalmology
- Sight-threatening nature, and to administer prompt treatment with the aim of preventing blindness to the 2nd eye
- Temporal artery biopsy
- Vision lost usually permanent
- Prompt administration of steroids (with gastric protection) may allow for partial visual recovery
- Iv methylprednisolone 500m to 1g/day for 3 days, followed by oral prednisolone for 3 days
- Treatment continued until symptom resolution and ESR normalization, or 4 weeks
- In 25% cases 2nd eye is affected despite treatment/steroid administration– within a few days
describe NAION
- Inflammation of optic nerve due to ischaemia, not related to inflammation of arteries
Causes - Drop in BP
- Increase in blood viscosity
- Reduced blood flow around nerve
- Most AION’s are non-arteritic - 90% of AION cases
NAION
Risk factors
- Structural crowding of disc - cup is small/absent
- Common modifiable risk factors include DM, HBP, high cholesterol, smoking
NAION
Symptoms
- Sudden, painless unilateral vision loss, Over hours - days
- Often described as a blurring or cloudiness of vision
- Px may also report H/A (8-12% px’s)
NAION
Signs
- VA 6/18 to CF , May only be slightly reduced/normal in some individuals
- Diminished colour vision
- Hyperaemic, swollen disc with a few splinter shaped haemorrhages
- Altitudinal hemianopia – most commonly inferior
- Fellow eye has smaller or absent cup
NAION
Management
- Emergency referral to ophthalmology
- Sudden loss in vision warrants emergency referral according to CMGs
- No definitive treatment, some advocate short-term systemic steroid treatment
- Treatment of any underlying systemic predispositions
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Describe Posterior Ischaemic Optic Neuropathy (PION)
- Much rarer than AION
- Caused by ischaemia of the retrolaminar portion of the optic nerve supplied by the surrounding pial capillary plexus, which in turn is supplied by the plial branches of the ophthalmic artery.
- Diagnosis made only after other causes of retrobulbar optic neuropathy have been excluded (e.g. compression, inflammation
Describe Optic neuritis
Acute or subacute inflammatory or demyelinating process affecting the optic nerve
Optic neuritis
Ophthalmology classifications
Retrobulbar neuritis – normal appearance of the OD, at least initially
* Most common type in adults
* Frequently associated with MS
* Other causes: tuberculosis, syphilis, viral infections
Papillitis – disc hyperaemia/oedema, occasionally PP flame-shaped haemorrhages
* Most associated with diabetes
Neuroretinitis – papillitis and a macular scar
* 66% caused by cat scratch
