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OD 2 > A3. Neuro-ophthalmological disease > Flashcards

A3. Neuro-ophthalmological disease Flashcards

1
Q

what are the classifications for optic neuropathy by cause?

A
  1. Inflammatory
  2. Glaucomatous
  3. Ischaemic
  4. Hereditary
  5. bullet
  6. Nutritional and toxic
  7. Papilloedema
  8. Traumatic
  9. Compressive
  10. Infiltrative
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2
Q

define papilledema? what is it’s ddx?

A

Papilledema refers to optic disc edema secondary to elevated intracranial pressure (ICP). It is frequently bilateral.

It must be distinguished from optic disc swelling from other causes which is simply termed “optic disc edema”. Papilledema must also be distinguished from pseudo-papilledema such as optic disc drusen.

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3
Q

what are 4 symptoms of papiloedema?

A
  1. Headache occurs early in the morning and may wake the patient from sleep; may intensify with head movement, bending, or coughing
  2. Transient loss of vision associated with postural changes
  3. No other visual complaints initially
  4. Sudden nausea and vomiting, often projectile
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4
Q

2 ways to grade papiloedema

A
  1. Frisen Scale (less common)
  2. Describing as “Early”, “Acute”, “Chronic” & “Atrophic”
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5
Q

describe 4 early signs of papiloedema

A

Blurred disc margins
Swollen hyperaemic disc
Paton’s lines / folds
Dilatation of superficial capillaries

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6
Q

describe 5 acute signs of papiloedema

A
  1. Normal or reduced VA
  2. severe disc hyperaemia, moderate elevation with indistinct margins and absence of the physiological cup
  3. venous engorgement, peripapillary flame haemorrhages, frequently cotton wool spots
  4. as swelling increases, ONH appears enlarged
    circumferential retinal folds (Paton lines)
  5. enlarged blind spot
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7
Q

describe 3 chronic signs of papiloedema

A
  1. VA is variable and visual fields begin to constrict
  2. disc elevation without CWS and haemorrhages
  3. Nerve fibre loss
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8
Q

describe 7 atrophic/late stage signs of papiloedema

A
  1. VA severely impaired
  2. Prolonged raised ICP (intracranial pressure)
  3. Gross nerve fibre loss
  4. Lesser disc swelling
  5. Optic disc pallor
  6. Optic atrophy (6-8wks)
  7. Poor visual function
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9
Q

what is SVP? what does it indicate for norm and papiloedema?

A

pulsations caused by variation in the pressure gradient along the retinal vein as it traverses the lamina cribrosa.

as the intracranial pressure rises the intracranial pulse pressure rises to equal the intraocular pulse pressure and the spontaneous venous pulsations cease.

Thus it is shown that cessation of the spontaneous venous pulsation is a sensitive marker of raised intracranial pressure.

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10
Q

how to ddx papiloedema and pseudo papiloedema?

A

SVP is present in 80% of normal population.

Absent in Papilledema
Present in pseudopapilledema

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11
Q

Mx for papiloedema?

A

URGENT referral to a neurologist / neuro-ophthalmologist for:
CT scan
Brain MRI

Differentiate from pseudopapilloedema

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12
Q

what is optic neuritis?

A

Swelling of the optic disc caused by local inflammation. Associated with demyelinating disease linked with multiple sclerosis.

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13
Q

what are the causes of optic neuritis?

A

Children: mumps, meningitis, chicken pox, upper respiratory tract infections

Adults: viral infection, toxoplasmosis

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14
Q

10 SSx of optic neuritis?

A
  1. Mild to severe pain in or behind the eye, usually precedes vision loss by 1 or 2 days
  2. loss of vision to 6/18 – 6/60, lasts 2 to 4 weeks
  3. Usually unilateral

­4. Age typically 18 to 45 years

  1. Swollen and hyperemic disc but with lesser haemorrhage & CWS than papilloedema
  2. May have macular star
  3. RAPD
  4. Colour desaturation (image on left)
  5. Central scotoma
  6. May have cells in the vitreous
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15
Q

Mx for optic neuritis

A

URGENT referral to a neurologist / neuro-ophthalmologist
VA usually recovers to 6/12
Intravenous steroids

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16
Q

what are the 3 types of ischemic optic neuropathy?

A
  1. Non-arteritic Anterior Ischemic Optic Neuropathy (NAION)
  2. Arteritic Anterior Ischemic Optic Neuropathy (AAION)
  3. posterior ION (PION)
17
Q

cause of NAION? any predisposing factors?

A

caused by occlusion of the short posterior ciliary arteries resulting in partial or total infarction of the optic nerve head.

small physiological cupping
hypertension (very common)
diabetes mellitus
Usually over the age of 50, but younger than those who develop AAION.

18
Q

5 SSx of NAION?

A
  1. Sudden painless monocular visual loss, frequently on awakening
  2. VA normal or slightly reduced in 30% patients, moderate to severe impairment for the remainder
  3. visual field defects typically inferior altitudinal
  4. CV defect proportional to level of visual impairment
  5. diffuse or sectoral hyperamic disc swelling, often with splinter haemorrhage
19
Q

Mx for NAION?

A

IMMEDIATE referral

Treatment:
no definitive treatment
some advocate short-term systemic steroid treatment

20
Q

cause of AAION? any predisposing factors? GCA

A

ocular manifestation due to Giant Cell Arteritis (GCA).

Occurs in patients ≥55 years of age.

Antecedent or simultaneous headache, jaw claudication (pain with chewing), scalp tenderness especially over the superficial temporal arteries (e.g., tenderness with hair combing), proximal muscle and joint aches (polymyalgia rheumatica), anorexia, weight loss, or fever may occur.

21
Q

5 SSx of AAION?

A
  1. Sudden painless loss of vision, usually to CF (severe loss)
  2. Unilateral first, then progress to bilateral within days
  3. Optic disc pallor and oedema, with surrounding flame-shaped haemorrhage
  4. VF defect
  5. RAPD
  6. Colour desaturation
  7. Optic atrophy within 4-8wks
  8. Prognosis is poor, visual loss is usually permanent
22
Q

what is Giant cell arteritis (GCA)? some ssx?

A

disease of blood vessels, may occur together with polymyalgia rheumatica.

occurs only in older adults, and can cause swelling and thickening of the temporal artery.

ssx:
-temporal headache
-scalp tenderness
- mini stroke

23
Q

Mx for AAION?

A

-IMMEDIATE referral

-Prime medical emergency in Ophthalmology as early detection and treatment can prevent further vision loss

-Erythrocyte Sedimentation Rate (ESR): A test to detect inflammation – rule out GCA!
-Temporal artery biopsy
-Corticosteroids
-Aim of treatment is to prevent progression to fellow eye

24
Q

what is RAPD? what test is used to detect it?

A

Marcus Gunn response
Determined by “swinging flashlight test”

25
Q

causes of RAPD?

A

Causes:

-Any optic nerve disease (examples)
-Optic neuritis/papillitis
-Unilateral optic neuropathies
-Severe glaucoma
-ON damage following trauma, tumour, infections, etc.
-Any large or severe retinal lesions (examples)
Large RD, CRVO, CRAO, etc.

26
Q

what are the two types of abnormal light-near dissociation?

A

adie’s (tonic) pupil
horner’s syndrome

27
Q

5 SSx of adie’s (tonic) pupil?

A

1-Unilateral, dilated pupil with decreased response to light
2-Sluggish near response
3-Dilated pupil becomes miotic over time
4-Usually in 20-40yo women
5-Photophobia & asthenopia

28
Q

what is the pharmacology testing for adie’s (tonic) pupil? 2 causes?

A

Rapid miotic response to diluted (0.125%) pilocarpine eye drop

causes:
1. Denervation of the postganglionic supply to the sphincter pupillae and the ciliary muscle due to viral illness

  1. Mostly idiopathic although rarely there can be local disorders within order including tumour, inflammation, trauma, etc.
29
Q

Mx for adie’s (tonic) pupil?

A

Most patients don’t need any treatment if diagnosis is confirmed

Unequal near additions

Tinted lenses

30
Q

5 SSx of horner’s syndrome pupil?

A
  1. Usually unilateral
  2. Mild Ptosis
  3. Miosis resulting from unopposed action of sphincter pupillae
    Therefore, anisocoria is greatest in dim illumination since the Horner’s pupil does not dilate well
  4. Reduced Ipsilateral sweating in some cases
  5. Hypochromic heterochromia (if congenital or long-standing)
  6. normal reaction to light and near reflexes
31
Q

what is the pharmacology testing for horner’s syndrome pupil?

A

Apraclonidine 0.5% or 1.0% - one drop instilled in both eyes, Horner pupil will dilate but a normal pupil will not be affected

Cocaine 4% - one drop instilled in both eyes, normal pupil will dilate but not Horner pupil

32
Q

3 causes of horner’s syndrome pupil? C P PO

A
  1. Central (first-order neuron)
    -Stroke
    -Tumor
  2. Pre-ganglionic (second-order neuron)
    -Tumor
    -Neuroblastoma in children
  3. Post-ganglionic (third-order neuron)
    -Migraine
    -Trauma
    -Carotid disease
    -Cavernous sinus tumor
33
Q

Mx for horner’s syndrome pupil?

A

Refer immediately to rule out major causes

OD 2 (7 decks)

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