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
2
Q
Describe the afferent visual system
A
- Affects visual pathway “towards the brain”
3
Q
Describe efferent visual system
A
- effects “from the brain” to the target
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
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
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
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
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
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
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
11
Q
Describe the characteristics of a migraine
A
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
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
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
- Usually visual
- Throbbing pain follows aura
- Anorexia, nausea, noise and light sensitivity
- Non-visual sx
- Hemiparesis
- Dysphagia
- Cloudy thinking
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
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
- Cerebral migraine
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!
- Type 1
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
