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1 Neuro Eye Diseases > MT1 > Flashcards

MT1 Flashcards

1
Q

Name for sympathetic problem- pupil won’t dilate in dim lighting

A

Oculosympathetic paresis/horners

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2
Q

Name for parasympathetic problem- pupil won’t constrict in bright lighting

A

Internal ophthalmoplegia

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3
Q

Au sign

A

Think pt is malingering about uveitis. Shine light in normal eye- uveitis eye should still hurt from constriction.

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4
Q

Pathway of neurons from GC axons to edinger westphal

A

GC axons– optic nerve – chiasm – optic tract (Dessecate)
Some go to LGN, others go to pretectal nucleus in the midbrain.

From pretectal nucleus, fibers travel and descassate at the posterior commissure, then half go to ipsi EW and half go to contra EW

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5
Q

(+) APD? Where is the disease

What should you do if the nerve looks normal?

A

Anywhere from ganglion cell to anterior knee of the chiasm

Order MRI of the orbits

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6
Q

Indirect APD test

A

If one pupil is fixed because posterior synechiae or something else- if you shine light into it, look at the consensual response of the other eye. Compare it with direct response of the other eye.

Direct > Consensual of the same, good eye? APD of fixed eye.

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7
Q

2 other ways to determine if pt has an APD

A

Pupil cycle time- count 100 cycles. 954msec is normal.

RAPDX

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8
Q

Light near dissociated pupil occurs in

A
  • Amaurotic pupil (APD/marcus gun??????)
  • Tonic Pupil (affecting ciliary ganglion, large pupil abnormal)
  • Argyll Robertson (affecting brainstem, small pupil abnormal)
  • Tectal pupils
  • Tabes diabetica
  • Aberrant regeneration of CNIII
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9
Q

3 steps to eval anisocoria

A
  1. Is it pathological or congenital? (Primary essential anisocoria in 15% of population)
  2. Which eye is abnormal?
  3. Is it due to the muscle, NMJ, nerve, or brain?
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10
Q

Amaurotic pupil

A

Completely blind eye with APD/Marcus Gunn

Has light near dissociation

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11
Q

APD is a monocular or biolcular phenomenon

A

Bi-ocular because when you shine light in the bad eye, both eyes will dilate

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12
Q

Pt presents with poor VA and no APD? 6 things could be causing decreased acuity

A
  1. Refractive error
  2. Media opacities
  3. Suppression amblyopia
  4. Stress syndrome
  5. Macular lesion
  6. Anterior chiasmal syndrome
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13
Q

What could be the causes of an abnormally dilated pupil?

A

Paresis of the sphincter (more common)

Dilator irritation- less common

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14
Q

What could be the causes of an abnormally constricted pupil?

A

Paresis of the dilator (Horners)

Sphicter irritation- common in anterior uveitis

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15
Q

large pupil due to a muscle problem

A

Posterior Synechiae
Narrow angle glaucoma
Ocular trauma (irido-dialysis)

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16
Q

Law of denervation supersensitivity

When to do this?

A

Do this if you think your patient has a pharmacological induced dilated pupil!!!! or Tonic pupil!!
Low concentration of pilo.
Normal or pharmacologically dilated eye? No constriction.
Tonic pupil? Constriction

Defect in CN III? NMJ becomes very sensitive to low concentration of ach. Will react more- constrict more than the normal eye.
BUT don’t ever put drops in the eye of someone who has a CN III palsy!!!!!!!!!!!!!!!

Tonic pupil will constrict

So. Abnormally dilated pupil. P sure its not CN III palsy. Do dilute pilo test. No constriction? No synechiae, cyclo-dialysis or glaucoma? 99% sure its due to pharm

Dilute pilo test:
Normal or pharm- no constriction
Tonic or palsy- constriction

17
Q

What is the most common cause of a fixed dilated pupil?

A

Drugs

18
Q

Large pupil due to a nerve problem

A
  1. Tadpole pupil. Spasm of the dilator muscle. Goes away in 1-2 weeks
  2. Tonic pupil
  3. CN IIII palsy
19
Q

3 types of tonic pupils that all look the same

A
  1. Local- Tumor, varicella infection, damage due to surgery
  2. Neuropathic - Syphillis, DM, sarcoidosis (people are usually aware they have a disease)
  3. Aides/Idiopathic
20
Q

Stats about Aides

A

Women 20-40
90% unilateral
80% symptomatic - 72% aniso, 35% blurry vision and ciliary muscle related problems

21
Q

4 qualities to look at size and shape of tonic pupils

A

Sector paralysis - flat is abnormal
Stromal stream- dynamic. Stream towards working sphincter.
Pigment seam- ectropion is normal
Stromal spread- tight stromal fibers are normal

22
Q

Ciliary ganglion 30: 1

A

30 accommodative fibers: 1 pupilomotor

23
Q

A tonic pupil does not always mean a problem with the ciliary ganglion. Other cause?

A

Traumatic iridoplegia- damage to short ciliary nerves
Post or preganglionic denervation
Regeneration of CN III
Midbrain oculomotor sign

24
Q

Supersensitivity testing using accommodation

A
  1. Refract to 20/20
  2. Drop with pilo
  3. Refract to 20/30
    Affected eye will have greater increase in myopia
25
Q

Pt with aides - how do you treat
Accommodative paralysis?
Accommodative spasm?

A

pilo

Tropicamide

26
Q

Holme’s Aides

Ross’s

A

Aides + Diminished deep tendon reflex

Aides + Diminished deep tendon reflex + excessive sweating

27
Q

Acute onset of painful CN III palsy with pupil involvement

A

Aneurysm of posterior communicating artery
*Can start out small, but then blows.

Compresses CN III-pupil fibers on the periphery of the nerve.

28
Q

Acute onset of painful CN III palsy withOUT pupil involvement

A

DM of ischemic vascular etiology
Needs medical referral to internist

This occurs because infarct occurs in the core of CNIII, pupil fibers run on the outside of CNIII.

29
Q

See mixed cranial nerve palsies in 1 eye?

A

Think MG then cavernous sinus then diabetes

30
Q

OD larger in bright, and OD smaller in dim?

with and without EOM involvement. Where is the lesion?

A

With EOM involvement? Think cavernous sinus.

WithOUT EOM involvement? Think ciliary ganglion

31
Q

Large pupil due to a brain problem

A

Uncal- Truma, hemorrhage of the uncus in the temporal lobe, which compresses the brainstem/CN III. Likely to lead to death. Always get brain scan after head trauma.
Hutchinsons pupil- fixed dilated pupil associated with Uncal

Parinaud syndrome- Tumor of the pineal gland. See earlier puberty. Near light dissociation.

32
Q

Hutchinsons pupil is a fixed dilated pupil associated with what

A

Uncal syndrome- Uncus hemorrhage due to trauma, causing CN III palsy.
Initially, pupil is mitotic, then becomes dilated on the same side as the mass. Can eventually become bilateral.

33
Q

Signs of parinauds syndrome

A

Light near dissociated pupil
Convergence retraction nystagmus - attempt to look up, get convergence and nystagmus.
Lid retraction (Colliers sign)
Precocious puberty

1 Neuro Eye Diseases (3 decks)

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