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Fall 2014 Neuro Ophthalmic Disease > Fall 2014: Lecture 1: Neuro Ophthalmic Exam > Flashcards

Fall 2014: Lecture 1: Neuro Ophthalmic Exam Flashcards

1
Q

Visual Function: 8 Tests

A
  1. VAs
  2. Contrast Sensitivity
  3. Stereoacuity
  4. Color Vision
  5. Color Saturation
  6. Photostress Recovery Test
  7. Pulfrich Phenomenon
  8. Visual Field
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2
Q

Visual Acuity

  1. Rosenbaum Card
    a. Purpose
    b. Pinhole?
  2. Feinbloom Designs for Vision (FDV)
    a. Purpose
    b. How can you fool people with this chart?
    c. What about people w/Count Fingers?
A
  1. a. Used A lot. Helps us determine how much vision is affected by a cataract and how much by an Optic Neuropathy
    b. Pinhole helps distinguish b/w the 2.
  2. a. to determine if a Pt truly is blind or extent of VA loss, vs Malingerers.
    b. They will think that since the letters are bigger than Snellen, that they’re supposed to see them, but it will tell us what their VAs are.
    c. Their VA is worse than 20/400, so use this chart to get a good estimate.
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3
Q

VA:

  1. Potential Pinhole Acuity (PPA)
    a. Helps us differentiate what?
    b. How is it performed?
A
  1. a. If VA loss is from a Cataract or from Retinal/Neurologic VA loss.
    b. Pt reads near card thru Pinhole while examiner shines Penlight onto the near card.
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4
Q

Contrast Sensitivity

  1. This is usually Abnormal in Pts with what 3 TYPES of Diseases?
    a. Sine Wave Grating: Used in Pts with VISUAL COMPLAINTS who have what?
A
  1. CATARACTS, Maculopathies, and Optic Neuropathies! (Pelli-Robson)
    a. How have NL Exam (Normal)
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5
Q

Stereoacuity

  1. Measures Depth Perception. Abnormal in what?
A
  1. Strabismus
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6
Q

Color Vision

  1. 2 Types of Tests
  2. Anomalous in what 2 types of Diseases?
A
  1. ISHIHARA and HRR

2. Acquired Optic Nerve or Retinal Dz.

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7
Q

Color Saturation

  1. RED CAP TEST
    a. Abnormal in what 2 Dzs?
    b. DO NOT DO what lighting tests prior to this test?
    c. It’s a Color comparison Test done Mono/Bino?

d. How is it done?
e. The Pt should be asked to Quantify what?

A
  1. a. Central VF and Optic Chiasmal Dz (Optic Neuropathy pallor, Brain tumor (Pituitary Adenoma)
    b. Do not do BRIGHT LIGHT Testing prior to this test.
    c. MONOCULAR
    d. Pass the Cap from Temporal to NASAL FIELD to assess for CHIASMAL Dz, crossing the Horizontal midline
    e. the Red Desaturation (% of NL)
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8
Q

Photostress Recovery

  1. Differentiates b/w what 2 Dz types?
  2. What is done?
  3. Recovery Delay occurs in what?
  4. What happens to someone that has a Macular Dz?
  5. What about an Optic Neuropathy?
A
  1. Macular Dz or Optic Neuropathy
  2. Recovery of Retinal sensitivity after exposure to a BRIGHT LIGHT based on Regeneration of RPE cells that were bleached during exposure to light.
  3. in DZ that AFFECTS the PHOTORECEPTORS; INDEPENDENT of NEURAL PATHWAYS!!!
  4. Someone that says they cant see your FACE but can see your body after SLE is a MACULAR Dz PROBLEM and it takes them about 1-2 MINUTES to RECOVER!!!
  5. They won’t have trouble with the Photostress recovery
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9
Q

Optic neuropathy

  1. Measure VA how?
    a. Pt will look into the BRIGHT LIGHT MONOCULARLY for how long?
    b. What would you do next?
    c. Normal?

d. Who will struggle with this?

A
  1. Monocularly
    a. for about 10 seconds, holding the light a few cm from the eye.
    b. Document time taken for VA to return to w/in 1 line of BCVA.
    c. Normal is <30 seconds, SYMMETRIC b/w the 2 eyes.

d. Peeps w/ARMD will have trouble (Retinal Problem). Optic Neuropathy will be fine.

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10
Q

Pulfrich Phenomenon

  1. You see a perceived path of light. What happens when you put a filter in front of the eye?
    a. Who gets this type of phenomenon in their eyes?
A
  1. You will see something swinging as an elliptical pattern.
    a. People with MS, and other OPTIC NEURITIS’. (Light not getting processed as fast). Or peeps w/Asymmetric or Unilateral Optic Neuropathy would be the ones.
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11
Q

Visual Fields

  1. Amsler Grid
  2. CFs
  3. Tangent Screen
  4. Goldman Kinetic VF
  5. Octopus
A
  1. Tests Small Areas
  2. Gross VF test.
  3. Valuable when you don’t have other tests and gives a little more detail.
  4. Tests the Entire VF
  5. Newer Technology Goldman Kinetic VF and will test the ENTIRE VF
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12
Q

Pupils

  1. Colvard Infrared Pupillometer
    a. What is it mainly used for?
  2. When using the NEUTRAL DENSITY FILTER, which eye do u put it over?
A
  1. a. People undergoing Refractive Sx (LASIK). MOST ACCURATE MEASUREMENT
  2. Put it over the GOOD eye until the APD GOES AWAY!
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13
Q

Ocular Motility

  1. Name 10 tests
A
  1. Smooth Pursuits
  2. Saccades
  3. Convergence
  4. CT
  5. Nystagmus
  6. OKN
  7. VOR
  8. OCR (Oculocephalic Response)
  9. Forced Duction Testing
  10. Bell Phenomenon
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14
Q

Smooth Pursuits

  1. Purpose?
  2. What test?
A
  1. Hold the image of a moving target on the fovea

2. EOMs Testing

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15
Q

Saccades

  1. Purpose
  2. What is it?
A
  1. To bring objects of interest onto the Fovea

2. Horizontal & Vertical Fast-Phase Eye Movements

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16
Q

Convergence

  1. Purpose
A
  1. Move eyes in opposite directions so an object is placed on the fovea.

(NPC and NEAR TRIAD)

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17
Q

CT

  1. Purpose
  2. Maddox Rod: Used to Measure what?
A
  1. Measure eye alignment in PRIMARY GAZE

2. Measure Eye Alignment in ALL AREAS OF GAZE

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18
Q

OKN

  1. Stimulus produces what?
  2. OKN Response is what?
  3. An INTACT OKN Response confirms a VA of what?
A
  1. JERK NYSTAGMUS in Pts w/GOOD VISION & Intact Oculomotor Systems
  2. OKN Response is Involuntary & Difficult to Suppress
  3. of 20/400 or BETTER!
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19
Q

OKN: When to test and Why?

  1. Infants & Infants w/Congenital Nystagmus
  2. Suspect Malingerer
  3. Suspect Intracranial Lesion
    a. What kind of lesion?
  4. Homonymous Hemianopsia (rarely)
    a. Symmetric OKN
    b. Asymmetric OKN
A
  1. +OKN = Intact Vision; Reverse OKN Response
  2. +OKN = VA: 20/400 or Better and CAN BE DONE MONOCULARLY
  3. PARIETAL LESION; Reduced response when drum is moved in the direction of the Parietal Lesion
  4. a. Likely Occipital Vascular Lesion (Most Likely a Stroke)
    b. Likely Parietal Mass Lesion
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20
Q

VOR

  1. Purpose
  2. Assessment of what 2 functions?
  3. Assists in Localization of what?
  4. Head Thrust Test
A
  1. Reflex to hold images steady on the retina to maintain clear vision during brief head rotation or body movement
  2. Vestibular and Brainstem Function
  3. of a Unilateral or Bilateral Semicircular Canal Deficit
  4. Have Pt relax, have them look at your nose. Thrust their head side-to-side (Eyes should be able to stay exactly where u tell them to look. If they move, then they have an Abnormality!)
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21
Q

Oculocephalic Response

  1. It’s a form of what?
  2. Test of the function of what?
  3. Doll’s EYE TEST: What is it?
    a. It should NOT be performed on what Pts?
A
  1. of VOR
  2. of the Brainstem
  3. Do this on Comatose Pts to ensure good brain stem function. DO NOT do this on Pts who have had a Hx of Cervical/Head Trauma and can move them more out of alignment.
    a. Should not be performed w/Cervical or Head Trauma.
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22
Q

Forced Duction Test (REMEMBER THIS!!)

  1. What does it differentiate b/w?
    a. how is it performed?
  2. Test is (+)
  3. Test is (-)
A
  1. PARESIS and RESTRICTION
    a. Put 2 gtts of Proparacaine in the Affected Eye. Try to move the eye by pulling on the Conj w/Forceps or a Cotton Swab. If you can MOVE IT, then you are probably dealing w/a CRANIAL NERVE PALSY (Paresis).
    * If you can’t move it, you might have a TUMOR in there or some sort of MASS!
  2. Means RESTRICTION and thus u have a TUMOR
  3. Means u have MOVEMENT and u probably have a CN PALSY (Paresis)
    * Document +/- Forced Duction Test
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23
Q

Cranial Nerves

  1. Test?
    a. What 3 things r good to use?
    b. WHAT should u NOT use?
A
  1. Identify Odor placed under each nostril.
    a. Coffee, Cloves, Lemon
    b. Avoid AMMONIA (stimulated CN 5)
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24
Q

CN 2

  1. What tests?
A
  1. VAs and VFs
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25
Q

CN 3

  1. What tests?
A
  1. Pupils, Accommodation, Eyelid Elevation, EOMS (Up, down, medial)
26
Q

CN 4

  1. Test?
A
  1. EOMS: Down and IN toward Nose (Reading)
27
Q

CN 5

  1. What does it test?
A
  1. Sensation of Face (V1, V2, V3) and Jaw Movement and Corneal Reflex (Cotton wisp test)
28
Q

CN 6

  1. Test
A
  1. EOMS: Temporal
29
Q

CN 7

  1. How to test Facial Muscles?
  2. Taste?
  3. What else?
A
  1. Wrinkle forehead; Smile showing teeth
  2. Ant 2/3 of the Tongue
  3. Eyelid Closure (Wink Eyes)
    * Document Asymmetrical Movement or Facial Drooping
30
Q

CN 8

  1. What does it test?
  2. How to test GROSS HEARING?
  3. RINNE TEST
  4. WEBER TEST
A
  1. Hearing and Balance
  2. Use watch or rub fingers close to ears
  3. tuning fork Placed on MASTOID PROCESS; Pt Vocalizes when sound disappears, then tuning fork head in front of the ear (NL = Pt should hear sound)
  4. Tuning fork placed on MIDDLE of the FOREHEAD; Pt Volcalizes which ear hears sound louder (NL = EQUAL)
31
Q

CN 9

  1. Test?
A
  1. Taste: Posterior 1/3 of the Tongue
32
Q

CN 10

  1. AUTONOMIC FUNCTIONS (What 5)?
  2. “Ahh” Test
  3. Gag Reflex: Stimulate what?
A
  1. Cough, Gag Reflex, Swallowing, Articulation, Phonation
  2. Soft Palate Elevates (UVULA MIDLINE)
  3. Back of Pharynx w/Tongue Depressor.
    * Note any difficulties w/Articulation and/or Speech
33
Q

CN 11

  1. Trapezius Muscle: Does what?
  2. Sternocleidomastoid Muscle: How to test?
A
  1. Shoulder shrugging (Raise both shoulders w/examiner Resistance)
  2. Shoulder & Head Movement: Turn head to the left & right w/Examiner Resistance
34
Q

CN 12

  1. What does it do?
A
  1. Tongue Movement/Strength

* NL = Stick tongue out and should be at Midline. Deviation = Problem.

35
Q

Vitals: Temperature

  1. Increased Possible infection w/Increasing Temperature
A
  1. Less than 98.6 = AFEBRILE (Think Pre Septal Cellulitis)

w/Temperature = Orbital Cellulitis

36
Q

Vitals: BP (JNC8 NORMS)

  1. Age 18-59: Healthy; or 60+ w/DM or CKD (Chronic Kidney Dz)
  2. Age 60+ Healthy
A
  1. <150/90 mmHg

* We r much more lenient now on putting these Pts on Medications

37
Q

Vitals: Heart Rate

  1. Brady Cardia
  2. Tachycardia
  3. Newborns
  4. Age 1-10
  5. Age 10+
A
  1. Less than 60 BPM
  2. More than 100 BPM
  3. 100-160 BPM
  4. 70-120 BPM
  5. 60-100 BPM
38
Q

Carotid Auscultation

  1. Place Stethoscope over what?
  2. Carotid Bruit: What is it?
  3. Carotid Stenosis:
A
  1. Over Carotid Artery; Opposite Hand placed over other Carotid Artery.
    * Pt Holds breath w/o Valsalva; Pulse is normally heard but w/o other sounds at systole.
  2. Audible Vascular swishing sound associated w/Turbulent BF.
  3. Increased Risk Factor for CVA.
    * Absent Bruit does NOT NEGATE RISK
39
Q

Orbital Auscultation

  1. Stethescope Bell applied over eye. Opposite hand placed over other Carotid Artery. Pt then does what?
  2. Orbital Bruit: What is it?
    a. What about if you hear it in CHILDREN under AGE 6?
  3. Causes?
A
  1. Pt Holds breath w/o Valsalva
  2. Faint, High-Pitched Vascular Sound, ESPECIALLY at SYSTOLE PHASE!
    a. It’s NORMAL
  3. a. High Cardiac Output States
    b. Severe ANEMIA
    c. Carotid-Cavernous Sinus Fistula (CCSF)
    d. Arteriovenous Malformation (AVM)
    e. Cerebral Hemangioma
40
Q

Temporal Artery Palpation

  1. Purpose?
    a. What do you feel for?
    b. What should you NOT FEEL?
    c. What should they NOT HAVE?
A
  1. GCA risk
    a. For symmetric pulse on each side.

b. Thick, Ropy, or Nodular (GCA)
c. Should not have Tenderness on Palpation!

41
Q

Lymph Node Palpation

  1. Have Pt do what?
  2. Lymphadenopathy: What is it?
    a. Cause?
A
  1. Flex their Neck; Palpate Both sides at the SAME TIME. Not any MASS or TENDERNESS!
  2. Swelling of Lymph Nodes
    a. Infection, CA, or other causes.
42
Q

Sinus Transillumination

  1. What can u see w/a Transilluminator?
  2. How to see Maxillary Sinus?
  3. How to see Frontal Sinus?
A
  1. Maxillary and Frontal Sinuses
  2. Shine light on Pt’s cheek. If sinuses are clear, observe glow of hard palate
  3. Shine light on nasal aspect of orbit, just below eyebrow. If sinuses are CLEAR, you’ll observe Glow w/in Forehead.
43
Q

Greater Occipital Nerve Palpation

  1. What could it be?
  2. What do they have?
  3. Pretty Rare to go from back of the eye to the front of the eye…99% of the time it’s what?
A
  1. Greater Occipital Neuralgia
  2. Paroxysmal Jabbing at Greater or Lesser Occipital Nerves accompanies w/Hypoesthesia or Dysesthesia!
    * Doc: Tenderness as well!
  3. Dry Eye.
44
Q

Neck Extension & Flexion

  1. MENINGITIS TRIAD: What is it?
    a. Neck Resists what?
  2. L-HERMITTE SIGN?
  3. Possible Etiologies?
A
  1. Fever, HA, Nuchal Rigidity
    a. Passive Flexion
  2. Electrical SENSATION that runs down the BACK and into LIMBS w/NECK EXTENSION or FLEXION
  3. MS and other spinal cord etiologies.
45
Q

Exophthalmometry

  1. Document what?
  2. Norms
    a. Caucasian Male
    b. Caucasian Female
    c. Black Male
    d. Black Female
A
  1. Document Lateral Separation and the device used.

(Hertel or Luedde)

  1. a. 12-21 mm
    b. 12-20 mm
    c. 12-24 mm
    d. 12-23 mm
46
Q

Eyelid Exam: Marginal Reflex Distance

  1. Used to evaluate what?
  2. Primary Gaze: Penlight Focused where?
  3. Use light reflex to measure what?
A
  1. Eyelid Margin Symmetry b/w each eye.
  2. At CENTER of the PUPIL
  3. Upper Lid Margin (MRD1) and below to Lower Lid Margin (MRD2)
    * What to see SYMMETRY b/w them.
47
Q

Eyelid Exam: Levator Function

  1. Measuring extent of what?
  2. Norms:
    a. Good
    b. Fair
    c. Poor
A
  1. of Eyelid Movement on Down and UPGAZE
  2. a. 8mm and up
    b. 5-7mm
    c. 4 mm or less
48
Q

Ancillary Testing

  1. 9 tests
A
  1. Electrodiagnostics
  2. FA
  3. OCT
  4. B-Scan Echography (Ultrasound)
  5. Neuro and Vascular Imaging
  6. Serology
  7. LP
  8. Temporal Artery Biopsy
  9. Tensilon Testing
49
Q

Electrodiagnostics

  1. ERG: Tests?
    a. How?
    b. Full-Field ERG
    c. Purpose

5 Main use for these tests?

A
  1. Measure Electrical Activity of the RETINA in response to a light stimulus.
    a. CL worn w/Anesthesia.

b. Stimulates ENTIRE RETINA w/Flash of Light under varying conditions of Retinal adaptation to Dark and LIGHT (A-Wave (NEGATIVE): Photoreceptor LAYER; B-Wave (Positive): Inner Retina (Muller and Bipolar Cells); C-Wave (Negative): RPE and Photoreceptors)
c. Diffuse Retinal Dz of Generalized or Peripheral Vision loss (Might be normal in MACULOPATHIES or LOCALIZED RETINOPATHIES despite SEVERE VISION LOSS!)

  1. To try and understand unexplained loss of Vision and NL Fundus Exam.
50
Q

Multifocal ERG

  1. Tests what?
  2. Purpose?
A
  1. Tests 250 focal retinal locations w/in CENTRAL 30 DEGREES.
  2. Occult, Focal Retinal Dz w/in the MACULA! (ICSC Example)
51
Q

EOG

  1. Records what?
  2. Dark Adaptation:
  3. Light Adaptation: Amplitude of Light Peak = ?
  4. ARDEN RATIO:
  5. Purpose
  6. Used in Conjunction w/what?
A
  1. Electrical Potential change produced by eye movement when CORNEA is MORE + and RETINA more (-).
  2. Lights off. Saccades measured every SECOND b/w 2 STIMULI
  3. 2X’s the DARK TROUGH in NL PTs.
  4. > 1.8 in NL PEEPS
  5. Differentiate Retinal Dz. Test for Oculomotor DYSFUNCTION
  6. w/ERG for differentiation of retinal Dz.
    * Stargardt Dz, Best Dz, Advanced Drusen, Butterfly Pattern Dystrophy, Stationary Night Blindness (Dominant vs. Recessive)
52
Q

Visual-Evoked Potential

  1. used often with what?
  2. P100 LATENCY
A
  1. ERG
  2. Prolongation Associated w/ON PATHOLOGY!!!
    * Differentiates Retinal, ON, Cortical Dz; Infant/Child w/INTACT VISION; MALINGERING!
    * Scalp Electrodes over Occipital Region. Pt sees display w/Checkerboard pattern. Recordings are measured.
    * If no response w/Pattern VEP, use FLASH VEP!
53
Q

Electroencephalography

  1. Measures what?
  2. Use?
A
  1. Brain wave activity
  2. EPILEPSY (SEIZURES)
    Dementia, Coma, Narcolepsy, General Anesthesia w/Brain Symptoms. LOC (Loss of Consciousness)
54
Q

FA

  1. Purpose
A
  1. Study Vascular filling patterns for Choroid, Retina and Optic Nerve-Related Vision Loss. (Rapid sequence retinal Photography)
55
Q

OCT (Optical Coherence Tomography)

  1. Purpose
A
  1. Image Retinal and ON structures in vivo.
56
Q

B-Scan Echography

  1. Uses what?
  2. Detect what?
A
  1. High-Frequency sound waves to image the globe (ultrasound)
  2. ONH Drusen; Poor fundus view; IOFB, Tumor, TED, Sup. Oph. Vein; Posterior Scleritis
57
Q

LP

  1. Use
A
  1. Suspect: Meningitis, Elevated ICP, Infection, Inflammatory Condition; Infuse Spinal Anesthesia or Chemo.
    * Puncture at L3-L4
58
Q

Temporal Artery Bx

A
  1. Complete it w/in 14 DAYS of STEROID INITIATION!!

If Bx is NEGATIVE, do test on the other SIDE!

Evaluate for GIANT CELLS!!!

59
Q

Tensilon Test

  1. Drug?
  2. Dx?
  3. Side Effects?
A
  1. Edrophonium Injection
  2. MG Dx vs. other Neurologic Conditions
    * Use to monitor Ach Tx.
  3. Fainting and Respiratory Failure. *Need to have a CRASH CART…so medical setting.
    * Romberg Signs/Test: Pt stands, arms to side, eyes closed. To keep balance, Pt has to have good eye function, VOR (hearing) and good proprioception in FEET. LOSS of 1 = LOSS of BALANCE. (Have to have at least 2 intact to be OKAY!) (CEREBELLAR FUNCTION: + Rhomberg = LOSS of BALANCE!)
    * Finger-to-nose Test (FTN): tests for ATAXIA

Heel-To-Shin (HTS): For coordination of lower extremities.

60
Q

Reflex Function

  1. DEEP TENDON REFLEXES
A
  1. Tap tendon w/Hammer. Damage to UMN (spinal reflex UNINHIBITIED = REFLEX is HYPERACTIVE!!)
  2. Damage to LMN = Reflex arc interrupted: DTRs are DECREASED!
61
Q

Reflex Function

  1. Babinski Sign
A
  1. Plantar reflex test.
    a. + = upgoing great toe w/fanning of other toes = UMN LESION!

b. - = Downgoing Great toe.

62
Q

Gait and Stance

  1. Ataxic Gait = ?
  2. Shuffling/Festinating Gait = ?
A
  1. CEREBELLAR d/o

2. Parkinson’s Dz.

Fall 2014 Neuro Ophthalmic Disease (14 decks)

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