6.1.14 Assesses signs & sxs of neurological significance

Question 1

What are signs of ONH dysfunction?

Answer 1

• Reduced VA (both distance and near)
• Severely Impaired colour vision
• RAPD
• VF Defect
• Impaired Contrast Sensitivity

Question 2

Key parts of history when suspecting neuro-ophthalmology problems?

Answer 2

o General – Age, Gender, Occupation
o Chief complaint – onset, severity, duration and degree of recovery
o Visual Loss - Mono/Binocular, Distance, Near or both
o Diplopia – Mono/ Binocular, ptosis
o Headache
o Medical history – Diseases, medication, surgery, psychiatric history
o Social history

Question 3

Compare ONH disease and macular disease?

Answer 3

ONH Disease
* Severe dyschromatopsia
* Reduced brightness sense
* +ve RAPD
Macular Disease
* -veRAPD
* Mild Dyschromatopsia
* Augmented brightness

Question 4

Give examples of optic neuropathies?

Answer 4

• Inflammatory/Demyelinating
• Ischaemic
• Compressive
• Toxic
• Traumatic
• Hereditary/Congenital

Question 5

Describe optic neuritis?

Answer 5

Optic Neuritis: Inflammatory disorder of the optic nerve
Classification:
o Retrobulbar Neuritis
o Papillitis
o Neuroretinitis
Possible Causes:
o Demyelination (Multiple Sclerosis
o Viral infections
o Tuberculosis
o Syphillis
Symptoms
o Rapid loss of vision in one eye – progressive over one week
o Retrobulbar or Orbital pain – worse on eye movement
Signs
* Dyschromatopsia – red/green
* RAPD
* Central Scotoma
* VA reduced (6/18-6/60)
* VA starts to recover after ¾ weeks – but usually to an impaired level.
* Vision can continue to improve for up to 6 months
Management
* Urgent Referral to HES (1-2 WEEKS)
* Investigate underlying cause
* Intravenous steroids may be delivered, but majority of cases are not treated
unless due to underlying systemic cause – just monitored

Question 6

What is AION?

Answer 6

Infarction of the optic nerve head secondary to occlusion of the PCAs

Question 7

What is arteritic AION?

Answer 7

Due to GCA (an inflammation of medium and large artery walls, e.g: Superficial temporal
artery, Ophthalmic artery, PCA). Emergency referral for temporal artery biopsy, blood
test for ESR levels, and prompt oral/intravenous steroid administration.
Sx:
* Sudden unilateral vision loss
* Preceeding amaurosis fugax
* Possible periocular pain
* Headache, neck or temple pain
* Scalp tenderness
* Jaw claudication
* Weight loss
* Fatigue
* Muscle pain/stiffness
* Protruding temporal artery – pulseless, tender, doesn’t compress
Signs
* VA <6/60
* RAPD
* Swollen optic disc
* Possible CWS
* Possible flame haemorrhages
* Arcuate VF defect
AAION can also lead to:
* CRAO
* 3rd and 4th nerve palsy

Question 8

Describe non-arteritic AION?

Answer 8

Infarction of the optic nerve head due to PCA occlusion as a result of atherosclerosis. No
preceding amaurosis fugax.
Can be due to:
* hypertension
* diabetes
* heart disease
* carotid artery disease
Signs:
* Normal – severe reduction in VA
* RAPD
* Dyschromatopsia
* Altitudinal VF defect
* ONH signs:
o Diffuse or sectorial oedema
o Pale or mild hyperaemia
o Possible flame haemorrhages
Emergency Referral

Question 9

Describe traumatic optic neuropathy?

Answer 9

Traumatic Optic Neuropathy – History of impact to the head, face, orbit
o Mechanism – compression, direct injury, vasospasm, ischaemia
o Symptoms – uni/bilateral vision and VF loss
o Signs - +ve RAPD, the ONH is normal is most cases

Question 10

Describe papilloedema?

Answer 10

Swelling of the optic nerve head secondary to raised ICP due to a build-up of
cerebrospinal fluid.
Causes:
* Intracranial mass (tumour, meningitis, hydrocephalus)
* Idiopathic (Obese young women)
Symptoms
* Headache:
o often early morning or on waking
o worse on bending/coughing/sneezing
o Severe, gets progressively worse over weeks
* Nausea
* Vomiting
* Pulsatile tinnitus
* Vision:
o Normal
o Transient obscurations of vision (seconds-minutes)
o Reduced VA and visual field loss (longstanding/end-stages)
Signs
Early Stages (0-3 days)
* Normal vision
* Hyperaemia
* Blurred margins
* Loss of SVP
Established/acute (4-5 days)
* Transient obscuration of vision
* VA normal or reduced
* Severe hyperaemia
* Moderate/pronounced elevation
* Blurred margins
* ‘Filled in’ optic cup
* Engorged veins
* Flame haemorrhages and CWS
* Enlarged blind spot Chronic
* Variable VA
* Severe disc elevation
* No haemorrhages and CWS
* Shunt vessels or crystalline deposits on disc surface
Emergency Referral to HES for treatment such as:
* MRI
* Lumbar Puncture
* Treat underlying cause

Question 11

Describe chiasmal syndrome?

Answer 11

Chiasmal Syndrome - caused my lesions affecting the chiasma: pituitary adenomas, meningiomas,
craniopharyngiomas.
o Ocular Symptoms – possible gradual/acute, uni/bilateral, central/peripheral vision loss (depends on cause
and position of lesion.
o Systemic Symptoms – Headache, somnolence, body changes, disturbance of temperature regulation,
behaviour changes, disturbed appetite
o Visual Field Defect – All Respect Vertical Midline
o Anterior Chiasm – Central scotoma, Blindness in one eye, Hemianopic arcuate scotomas
o Body – Bitemporal superior quadrantanopia, Bitemporal hemianopia
o Posterior Chiasm – Bitemporal Hemianopic scotoma

Question 12

What VF defect would you expect with retrochiasmal lesion?

Answer 12

VF defect depends on location

Question 13

Describe diplopia and neuro-ophthalmology?

Answer 13

o Monocular – Cause: astigmatism, poorly fitting CL, keratoconus, dry eye, refractive surgery, iridectomy,
ectopia lentis, cataract, epi retinal membrane.
o If improves with blinking = dry eye, NIPH = macular lesion
o Binocular – Cause – Trauma, tumour, thyroid eye disease, entrapment, myopathy, dystrophy, CN palsies, tumours, injury, stroke, vascular process, neurodegeneration
o With vertical separation of objects and better with head tilt (CHP) – 4 th CN palsy
o Horizontal separation worse in distance – 6
th CN palsy