Eyes And Neuro-ophthalmology Flashcards
What is a Pel’s crisis?
A tabetic ocular crisis - acute intense pain in eye and light sensitivity associated with tertiary syphilis
What is a syphilitic ocular crisis called?
Pel’s crisis
What is an Argyll-Robertson pupil?
Bilateral small irregular and unequal pupils that accommodate (reduce in size when looking at a near object) but do not react to light (don’t constrict in bright light)
What is the name for bilateral small pupils that accommodate but don’t react to light? With what is this associated?
Argyll-Robertson pupil
Associated with syphilis
What is near-light dissociation?
A feature of Argyll Robertson pupil - accommodation to near objects but don’t react to light
Apart from AR, what is the general area of the lesion causing light near dissociation and what are 4 other differentials?
Midbrain - iridodilator nerve function Diabetes mellitus Alcoholic midbrain degeneration Tonic phase of Holmes Adie pupil Midbrain lesions - sarcoidosis, encephalitis, Parinaud's syndrome
What are the two alternative names for Parinaud’s syndrome?
Dorsal midbrain syndrome/vertical gaze palsy
What causes Parinaud’s syndrome?
Upper dorsal brainstem (midbrain) lesions - commonly pineal gland tumours
Leading to compression of the vertical gaze centre at the rostral interstitial nucleus of medial longitudinal fasciculus (riMLF)
What can pineal gland tumours/dorsal midbrain lesions cause and what do they disrupt to do this?
Parinaud’s syndrome, via disruption of the rostral interstitial nucleus of the medial longitudinal fasciculus riMLF
What are the 6 characteristic features of Parinaud’s syndrome?
Upgaze paralysis (supranuclear) Near-light dissociation Convergence retraction nystagmus (globes retract) Eyelid retraction Conjugate down gaze - setting sun sign Bilateral papilloedema
2 common causes of conjugate down gaze/setting sun sign?
Parinaud’s syndrome
Raised ICP - failed VP shunts
What is Colliers sign?
Eyelid retraction associated with dorsal upper midbrain lesion e.g. Parinaud’s syndrome, Miller Fisher syndrome
What is suggested by eyes in which you can see the sclera above the iris, which is exacerbated by attempted upgaze?
Collier’s sign - Parinaud’s syndrome
3 common patient groups with Parinaud’s syndrome?
Pineal/midbrain tumours e.g. Pinealoma/intracranial germinomas in young patients
Young women with MS
Older patients with upper brainstem stroke
Describe internuclear ophthalmoplegia?
Failure of adduction of the affected eye, with nystagmus of the unaffected eye and resultant horizontal diplopia (when looking to the non-affected side)
Lesions of what cause INO?
The medial longitudinal fasciculus
How does the MLF coordinate conjugate eye movement?
Connects the paramedian pontine reticular formation abducens nucleus complex of the contralateral side to the oculomotor nucleus of the ipsilateral side
What is the classical cause of bilateral INO?
MS - bilateral MLF lesions
What is a likely cause of unilateral INO in older patients?
Stroke affecting MLF region
What is one and a half syndrome of the eyes?
Lesion affecting the paramedian pontine reticular formation or abducens nucleus on one side and the MLF on the same side (which has crossed over) causes paralysis of all conjugate horizontal eye movements other than abduction of the eye on the opposite side of the lesion
What does painless optic neuritis suggest?
Less likely to be MS - consider ischaemic, compressive neuropathy
What is the Adie tonic pupil?
A tonically dilated pupil that reacts slowly to light but definitively to accommodation (light-near dissociation)
What is the name for a tonically dilated pupil that reacts slowly to light but quickly to accommodation?
Adie pupil
What is the Holmes Adie syndrome?
Tonic dilated Adie pupil plus impaired sweating/ANS dysfunction and absent knee/ankle jerks, often seen in women
What causes Adie syndrome?
Damage to the post-ganglionic fibres/ciliary ganglion of parasympathetic nervous system innervation of the eye and DRG ANS, often related to post-infection
What causes the ANS symptoms in Holmes Adie syndrome?
Damage to DRG in spinal cord
What test can be used to confirm a tonically dilated pupil?
Use of low dose pilocarpine, a constrictor which shouldn’t normally constrict in low dose. If it does so it suggests cholinergic denervation supersensitivity
What does painless optic neuritis suggest?
Less likely to be ms - consider e.g. Ischaemic or compressive optic neuropathy
What are cotton wool spots?
Micro-infarcts causing interruption of axonal transport and build up of opaque organelles
Where do flame haemorrhages arise from?
Haemorrhage within nerve fascicle bundles
Can a hemivisual field defect be due to an optic ischaemic event? Why/not?
No - vascular pattern to optic nerve does not allow it. Can have a lower or upper half defect but not nasal/temporal
