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Neuro-optometry > Lecture 1: Intro to Neuro-optometry & HAs > Flashcards

Lecture 1: Intro to Neuro-optometry & HAs Flashcards

1
Q

What is the most common cause of decreased acuity? (6)

A
  • Refractive error
  • Amblyopia
  • Media opacity
  • Retinal lesion/Macular lesion
  • Optic neuropathy
  • Non-physiologic/Functional causes
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2
Q

Describe the afferent visual system

A
  • Affects visual pathway “towards the brain”
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3
Q

Describe efferent visual system

A
  • effects “from the brain” to the target
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4
Q

What are the 8 elements of neuro-optometric eye exam?

A
  • Case hx
  • Acuity/Contrast sensitivity
  • Pupils
  • Color vision (red desaturaiton & color vision testing)
  • Amsler grid
  • Brightness comparison
  • Opthalmoscopy
  • VF
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5
Q

What are the 5 different types complaints that would raise suspicion about the patients HAs?

A
  • A new onset HA
  • A HA that is different from the previous type
  • A severe HA, “worst HA ever” (aneurysm)
  • HA that is present upon awakening (pathological etiology)
  • HA associated with focal neuroloical sx
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6
Q

Describe the theory on tension HAs

A
  • Connective tissue that links the linign of the brain (dura mater) with the upper neck muscles may be cause of tension HAs
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7
Q

List 3 pain-sensitive structures in the brain

A
  • Parts of the dura at the base of the skull
  • Venous sinuses and tributaries
  • Dural and cerebral arteries at the base of the brain
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8
Q

What are the 4 causes of extracranial HAs?

A
  • Fascia, muscles and galea
  • Extracranial arteries of the head and neck
  • Mucous membranes
  • Tympanic membranes
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9
Q

What are the 4 causes of intracranial HA?

A
  • Traction on arteries, veins and venous sinuses
  • Distention and dilation of intracranial arteries
  • Inflammation of pain sensitive structures
  • Direct pressure on cranial nerves and cervical nerves
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10
Q

90% of HAs are caused by __. Describe the sx

A
  • Tension/Anxiety HA (HA syndrome)
    • 90% of HAs
    • Emotional or physical stress
    • Muscle contraction
    • Sustained contaction of neck and scalp muscles
    • Pain is dull and non-throbbing, tightness
    • “band around head”, “head in a vise”
    • Depression is common
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11
Q

Describe the characteristics of a migraine

A
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12
Q

What are the different types of migraine? (7)

A
  • Migraine without aura (aka common migraine)
  • Migrain with aura (classic migraine)
  • Basilar artery migraine
  • Migrain aura without HA (aka acephalgic migraine)
  • Ophthalmoplegic migraine
  • Retina (ocular) migraine
  • Migraine equivalent or variant
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13
Q

What is common migraine?

A
  • Migraine without aura
    • ​Prodrome may occur hours or days before
    • Prodrome may include :
      • Mood, disorder, GI, distress, fatigue
    • Photophobia, nausea and or vomiting common
    • Anorexia (loss of appetite) common
    • Conjunctival injection and tearing common
    • No aura
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14
Q

What is classic migraine?

A
  • Migraine with aura
  • Sharply defined aura
    • Usually visual
      • Scintillating fortification scotoma
      • Hemianopia, monocular field loss, altitudinal field loss, tunnel vision, heat waves
    • Strong fam hx shows typical sx
    • Only about 20% of migraineurs
      • Last 20-40 mins
  • Throbbing pain follows aura
    • Anorexia, nausea, noise and light sensitivity
  • Non-visual sx
    • Hemiparesis
    • Dysphagia
    • Cloudy thinking
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15
Q

What is bickerstaff’s migraine?

A
  • Basilar artery migraine
    • Young women
    • Strong hx of migraine
    • Severe HA
    • Mimics vertebrobasilar insufficiency seen in elderly
      • Vomiting
      • Bilateral visual loss
      • Vertigo/Tinnitus/Hearing loss
      • Dysesthesia
      • Ataxia
      • Altered consciousness
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16
Q

What is acephalgic migraine?

A
  • Migraine Aura without Headache (aka Acephalgic migraine)
    • Neurologic sx without HA
    • Hx of migraine
    • Can occur at any age
    • Can be confused with TIA when pt over 40y
    • Visual sx
      • Scintillating scotoma
      • Typical march of scintillating scotomas
      • Transient hemianopia
      • Tunnel vision and diplopia
      • Altitudinal field loss
      • Amaurosis fugax
    • Other neurological sx frequently noted
17
Q

Acephalgic migraine warrants investigation when… ? (5)

A
  • Visual disturbance lasts longer than 60 minutes
  • Headache precedes the aura
  • Always in the same hemifield
  • Stationary visual disturbance
  • Fixed neurolgoic deficit present
18
Q

Describe ophthalmic migraine

A
  • Onset before age 10y
  • Hx of topical migraine
  • Usually affects CN III but can rarely also affect CN VI
    • Usuaully involves a pupil and accommodation
  • Opthalmoplegia follows at the heigh of headache and presists when headache clears
    • Ophthalmoplegia is ipsilateral to headache
19
Q

Describe retinal (ocular) migraine

A
  • Transient monocular visual disturbance
  • Typically in young pereson <40y
  • May last minutes to hours
  • May be due to temporary vasospasm of ocular circulation
  • Headache frequently absent during episode
  • Rule out embolic and vasculopathic disease
20
Q

Describe migraine equivalent or variant

A
  • Presumed cerebral ischemia
  • Symptoms appear migrainoid
    • Vomiting, nausea, abdominal pain, motion sickness, mood changes
  • Disorders associated with presumed transient cortical dysfunction
    • Central achromatopsia
    • Propasagnosia
    • Alexia
    • Transient global amnesia
    • Illusions of distortion in size and shape
21
Q

What are the complications of migraine?

A
  • Neurologic effects that last beyond headache phase
    • Cerebral migraine
      • Motor, visual and other sensory defects
      • Hemiplegic migraine
      • Transient homonymous or quadrantic VF loss
      • Speech disorders
22
Q

What is horton’s headache/ Histamine cephalgia

A
  • Cluster Headache
    • ​Recurrent, severe headache
    • Typically awakens pt in the morning
    • Severe pain in the external carotid distribution
      • Frontal
      • Fronto-temporal
    • Ipsilateral horner’s syndrome
      • 3rd order and may persist after episode
    • Lacrimation
    • Rhinorrhea
    • Conjunctival edema and injection
    • Usually 3rd to 4th decade
    • Male Preponderance
    • Tends to pace the floor until pain subsides
23
Q

What is Raeder’s syndrome?

A
  • Aka “reader’s para-trigeminal neuralgia”
    • Type 1
      • painful horner’s syndrome with pain in V1 distribution
      • Usually middle aged/elderly males
      • Migrainous dilation of internal carotid
        • Compresses V1 and sympathetic plexus in middle cranial fossa
        • Pain may last weeks or months
    • Type 2
      • Other cranial nerves involved
      • Rule out mass!
24
Q

Describe headaches associated with brain tumors/cranial disease

A
  • Sudden onset/appearance
  • Mild/intermittent but progressively worsens
  • Don’t respond well to typical headache treatment
  • Worse when coughing, straining, head down
  • May have other neurologic findings
  • Elevated intracranial pressure
    • Papilledema
    • CN VI palsy
25
Q

What are some other causes of HA?

A
  • Hypertension: check pt bp!
  • Temporal (cranial) arteritis:
    • new onset HA in pt over 60y
    • Bitemporal
    • Scalp tenderness
    • Jaw claudication
    • Polymyalgia
    • Visual sx
  • sinus disease
    • ​dull, aching, constant pain
    • Tenderness over involved sinus
    • Aggravated by change in pressure
  • TMJ
  • Fever
  • Ocular inflammation
  • Eyestrain
    • ​Precipitated by eye use
    • Relieved by rest
26
Q

Describe ice-pick headache

A
  • Aka idiopathic or primary stabbing headache
  • Unique HA with ultra-brief stabs of pain
  • Short, unilateral, neuralgiform, conjunctival injection and tearing (SUNCT)
  • Frontal or temporal area
  • Predominantly affects females, 2-35% of the population
  • No cranial autonomic sx but include nausea, vomiting, photophobia, dizziness
  • Primary
  • Secondary
    • ​Herpes zoster meningoencephalitis
    • Meningioma
    • Stroke
    • MS
27
Q

What are some treatments for ice-pick HA?

A
  • Indomethacin
  • Gabapentin
  • Cycloxygenase-2 inhibitors
  • Melatonin
28
Q

Describe a HA workup

A
  • Case hx
    • If H/A part of pt complaint or mentioned later during exam
    • Must look for reason for HA
      • Visual/refractive
      • Binocuarl vision issue
      • Systemic disease
      • Neurological disease
    • Check BP
    • Check refraction and prescription
      • Look for asthenopia
      • Look for induced prism
      • Incorrect PD
      • Incorrect base curves
    • Look for biocular dysfunction
      • Convergence/divergence or accommodative issues
    • Look for systemic casue of HA
      • Allergies, sinusitis, stress posture
  • Plan
    • Perform a formal VF exam to look for field loss
    • Educate pt to return ASAP if the HA persists
    • Refer the pt to their PCP for further evaluation
    • Record in chart

Neuro-optometry (3 decks)

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