Neuro 2.2 Flashcards
1
Q
Nystagmus
A
- Rhythmic, to and from eye movement due to:
- Inability to maintain fixation
- Loss of normal inhibitory influences on eye movement control system
- Loss of normally symmetrical input from one of the vestibular pathways to the ocular motor nuclei (if asymmetrical one overrides the other, eyes would move In one direction more than the other)
2
Q
Nystagmus - Phases
A
- Slow phase - eyes drift away from fixation point slowly
- Rapid phase - saccadic movement back to fixation point
Described by:
- Amplitude (how far eyes move) - coarse or fine
- Frequency (how fast eyes move) - low, moderate, high
3
Q
Nystagmus - Eye Movements
A
- Jerk
- Slow drift, fast saccadic correction (zig-zag)
- Pendular (most common)
- Non-saccadic in both directions, slow (squiggly line)
- Mixed
- Different eye movement on different positions of gaze
- e.g. pendular in primary position and jerk on lateral gaze
4
Q
Nystagmus - Types and Causes
A
- See-Saw (vertical nystagmus where one eye goes up and the other goes down)
- Midbrain lesions
- Pituitary tumours
- Severe visual loss
- Downbeat (eye drifts up slowly and then a quick down motion to the centre)
- Cerebellum lesions
- Medulla lesions
- Idiopathic
- Upbeat (eye drifts down slowly and then a quick up motion to the centre)
- Medullary lesions
- Cerebellum lesions
- Benign positional paroxysmal vertigo
- Abducting nystagmus of INO
- Demyelination
- Brainstem stroke
- Periodic Alternating (alternating eye movement)
- Arnold-Chiari
- Demyelination
- Trauma
- Encephalitis
- Syphilis
- Posterior fossa tumours
- Visual deprivation
- Pendular nystagmus
- Demyelination
- INO
- Brain stem dysfunction
- Spasmus Nutans
- Idiopathic in children
- Glioma
- Gaze-evoked (no nystagmus in primary position but when px moves their eyes they can get nystagmus in other positions of gaze
- Drugs
- Alcohol
5
Q
Nystagmus - Associated Symptoms
A
- Symptoms of demyelinating disease (loss of vision, eye pain, numbness, weakness, paraesthesia)
- Vertigo or oscillopsia (feeling world around you is moving) suggests vestibular system abnormality
- Deafness or tinnitus present in vestibular lesions
- Blurred vision
- Diplopia in particular positions of gaze (INO)
6
Q
Nystagmus - Ocular Motility
A
- Assess ocular stability in primary gaze (nystagmus? type?)
- Examine in 9 cardinal positions to determine if:
- Monocular or binocular?
- Conjugation - do eyes behave similarly?
- Abnormal movements are hor/vert/tors/mix?
- Abnormal movements are continuous or induced by particular eye positions?
- Slow/fast/both phases seen?
- Null point? (advise px’s to move tasks to area of least nystagmus)
- Head position, movements (adv may get a sore shoulders/neck due to holding head in abnormal position)
- Visual fields
- Romberg test - checks whether vestibular system affected
- Ask px to hold arms out, close eyes to see if they can stand still or whether they fall to one side - would suggest problem with vestibular system
7
Q
Nystagmus - Management
A
- Acquired - investigate for cause (urgency for referral depends on likely cause)
- Advice - null position, head position etc
- Refractive management, spectacle choices (especially when presbyopic - add may be slightly higher)
8
Q
Migraine
A
- Periodic headaches with complete resolution between attacks
- 80% have 1st attack before 30yrs
- Prevalence increases until 40yrs then decreases
- Twice as common in women
- Affects 7% of men and 20% of women
- 15% of females only have attacks around menstruation
9
Q
Migraine - Associations
A
- Certain foods (cheese, chocolate, coffee, red wine)
- Nausea or vomiting
- Photophobia
10
Q
Migraine - Attack Stages
A
- Prodrome (feeling of being unwell, know migraine is about to happen)
- Aura (visual disturbance, motor or sensory disturbance)
- Headache
- Resolution
- Not all migraines will have all 4 stages above
- Relieved by sleeping or going into a dark room
11
Q
Types of Migraine
A
- Common migraine
- Classical migraine
- Cluster headache
- Focal migraine
- Migraine sine migraine
- Retinal migraine
- Ophthalmoplegic migraine
- Familial hemiplegic migraine
- Basilar migraine
12
Q
Common Migraine
A
- Migraine without aura (migraine without aura 3x more common than migraine with aura)
- Headache and ANS dysfunction (pallor, nausea)
- Prodrome - changes in mood, yawning, poor concentration
- Headache - pounding or throbbing, can start anywhere and spreads to half or whole head, photophobic and sensitive to sound
- Lasts from hrs to a day
13
Q
Classical Migraine
A
- Visual aura for about 20 mins
- Looks like a paracentral scotoma - bright, positive (can’t see an area of the VF, but it looks bright)
- Fortification spectrum (jaggy lines) enlarges after a few mins, lined on inner edge with negative scotoma
- Positive scotoma, jaggy lines that start small get bigger and move across VF and then disappear (over 20 mins) with full visual recovery
- Scotoma expands and moves towards temporal periphery before breaking up
- Full visual recovery within 30 mins, if lasts more than an hour think of other causes
- Headache follows, usually opposite where the scotoma was
- Associated with nausea and photophobia
- Can vary in severity depending on px - headache can be absent, trivial, severe
- Visual aura without headache not uncommon in over 40s but always be a history of classical migraine in early 20s
*Positive scotomas - seen by the px (e.g. coloured light seen after staring at light for too long)
*Negative scotomas - blank spot in VF not seen by px (e.g. blind spot
14
Q
Cluster Headache
A
- Typically affects men in 30s and 40s
- Characteristic description of headaches - few headaches over a short period of time
- Can be almost every day for a period of weeks, can go years between clusters
- Severe headaches start suddenly
- Lasts 10 mins to 2 hrs
- Associated with ocular features, can be misdiagnosed as another ocular problem (lacrimation, conjunctival injection and rhinorroea)
15
Q
Focal Migraine
A
- Symptoms of migraine
- Transient dysphasia (language impairment - problems talking)
- Hemisensory symptoms
- Focal weakness
16
Q
Migraine sine Migraine
A
- Episodic visual disturbances without headache
- Typically elderly with history of classical migraine
17
Q
Retinal Migraine
A
- Rare
- Unilateral visual loss
- Differential diagnosis retinal embolism
- Similar to classical migraine but unilateral visual loss
- Permanent visual loss common with recurrent episodes
- Typically affects young women
18
Q
Ophthalmoplegic Migraine
A
- Rare
- Usually starts before age 10
- Recurrent headache followed by a 3rd nerve palsy
- Due to demyelinative diseases in most cases
19
Q
Facial Hemiplegic Migraine
A
- Failure of full recovery of neurological features after migraine
20
Q
Basilar Migraine
A
- Affects children
- Bilateral numbness/tingling of extremities and lips
- Ataxia of gait (uncoordinated movements) and speech can occur
- Sometimes loss of consciousness
21
Q
Migraine - Differential Diagnosis
A
- Acute PVD (can cause flashes) - monocular
- Retinal detachment
- TIA (shade/cloud that spreads centrally, lasts several mins, clears from centre)
- Transient visual obscuration’s (greying/darkening, papilledema, changes in posture, may precede AION in GCA)
- Occipital epilepsy (px can see coloured circles during epileptic attack)
22
Q
Facial Spasm - Causes
A
- Essential blepharospasm
- Facial hemispasm
- Bell’s palsy
23
Q
Essential Blepharospasm
A
- Uncommon but distressing
- Presents in 50s
- More common in females
24
Q
Essential Blepharospasm - Clinical Features
A
- Progressive bilateral involuntary spasm of orbicularis oculi and upper facial muscles
- Idiopathic, likely to be mixture of genetic and environment
- Predisposing factors - reading, driving, stress, bright light
- Alleviated by - talking, walking, relaxing
25
Q
Facial Spasm
A
- Unilateral
- Occurs in 40s to 50s
- Brief spasm of orbicularis oculi spreading along facial nerve
- Idiopathic most commonly (abnormal BV’s compressing on facial nerve)
- Or due to irritation to nucleus of nerve (e.g. tumour, stroke, MS)
- May occur several months/years after Bell’s palsy
26
Q
Bell’s Palsy
A
- Paralysis of facial nerve (7th CN)
- 72% of all facial palsy
- Annual incidence - 20 per 100,000
- Especially between ages 15-45
- Affects males and females equally (except in pregnancy)
More common in:
- Pregnancy (annual incidence increases to 45 per 100,000)
- Diabetes
- HIV
27
Q
Bell’s Palsy - Causes
A
- Unknown
- Sometimes associated with:
- Latent virus infection (HSV type 1, HZ)
- Influenza
- Respiratory tract infections
- Depleted immune system
- Stress
28
Q
Bell’s Palsy - Symptoms
A
- Sharp pain in the inner ear during the onset of paralysis
- Often don’t realise until pointed out by someone
- Impaired or altered sense of taste
- Sensitivity to loud noises
- Difficulty eating and speaking
- Distressing cosmetic change due to loss of muscle tone on one side of face
29
Q
Bell’s Palsy - Ocular Symptoms
A
- As eyes can’t shut properly, ocular exposure can cause:
- Redness
- Discomfort
- Pain
- Photophobia (if corneal surface is damaged)
- Watering of eye (epiphora) - as eyes cant close so tears not pumped away as usual, tears can spill over
30
Q
Bell’s Palsy - SIgns
A
- Eyebrow may drop
- Upper lid might retract and lower lid may be lower
- Eye appears bigger - as eyelids have moved further apart
- Corner of mouth can drop
31
Q
Bell’s Palsy - Ocular Signs
A
- Unilateral facial weakness including orbicularis oculi
- Incomplete blink leads to corneal drying - can cause dry eye symptoms
- Lagophthalmos (Incomplete closure at night) causes corneal exposure - can get extremely dry
- Loss of lacrimal pump mechanism produces pooling and epiphora
- Conjunctival hyperaemia, oedema, staining
- Corneal desiccation (area of cornea without sufficient tears) ranges from mild superficial punctate erosions to ulceration (usually inferior)
32
Q
Bell’s Palsy - Differential Diagnosis
A
- Part of a stroke (cerebro-vascular accident with hemiplegia)
- Infection (e.g. otitis media, Lyme disease)
- Trauma (e.g. cranial fracture, facial laceration)
- Tumour (e.g. acoustic neuroma: damage to nerve by tumour or secondary to surgical trauma)
- Ectropion/entropion - also cause watering and corneal exposure
Other causes of lagophthalmos:
- Orbital (thyroid eye disease)
- Mechanical (cicatricial – look for lid scarring)
- Physiological (px’s partner to check for full lid closure at night)
33
Q
Bell’s Palsy - Prognosis
A
- 82% recover normal function within 9 months
- Most improvement occurs within 3 weeks
- In the remaining 20-30%, px left with a degree of permanent facial paralysis
- Severe nerve damage more likely if:
- Over 60
- Severe pain at onset
- Complete rather than partial paralysis at onset
- Diabetes or HBP
- Pregnant at time of onset
- Recovery had not begun after six weeks
- 7% are recurrent, with a 10yr average interval between attacks
34
Q
Bell’s Palsy - Complications
A
- Contracture
- Shortening of facial muscles over time may make affected side of face look ‘lifted’
- Affected eye may appear smaller
- Fold between outer edge of nostril and corner of the mouth may seem deeper - due to the increased contraction of cheek muscles on that side
- Crocodile tears
- Affected eye waters involuntarily, especially whilst eating due to faulty ‘re-wiring’ of the nerves during recovery phase
- Synkinesis
- When intentionally trying to move one part of the face, another part automatically moves
- e.g. on smiling, the eye on the affected side automatically closes
35
Q
Bell’s Palsy - Management
A
- New cases and where loss of corneal sensation/corneal ulceration - emergency (same day) referral
- Improved prognosis in moderate/severe cases of Bell’s palsy if treated with systemic corticosteroids within 72 hours of onset
- Recovering and established cases - alleviation/palliation, no referral
- If cannot be managed easily - drugs, routine referral
- Tape lids closed at night to reduce exposure
- Sunglasses for photophobia and general protection
- Dry eye can be treated by artificial tears by day, unmedicated ointment at night
- Therapeutic CL’s considered if unresponsive to frequent use of ocular lubricants
Treatment by ophth:
- Urgent treatment for new cases with systemic steroids
- Surgery for permanently unrecovered cases
36
Q
Preseptal Cellulitis
A
- Infection of orbital tissues in front of orbital septum
37
Q
Preseptal Cellulitis - Causes
A
- Trauma around eye
- Spread of infection from nearby structures e.g. dacrocyctitis, hordeolum, recent eye surgery
- Spread of remote infection e.g. upper respiratory tract infection, impetigo (skin infection), recent surgery around eye
38
Q
Preseptal Cellulitis - Symptoms
A
- Unilateral
- Red tender swelling around eye
- Unwell px (fever, malaise, irritable child)
39
Q
Preseptal Cellulitis - Signs
A
- Lid oedema, warmth, tenderness
- Ptosis
- Fever
40
Q
Preseptal Cellulitis - Management
A
- CMG: “Emergency (same day) referral to ophth or A&E, no intervention”
Treatment by ophth:
- Confirmation of diagnosis, CT scan to see where area of inflammation is
- Systemic antibiotics
41
Q
Orbital Cellulitis
A
- Infection of orbital tissues behind the orbital septum
42
Q
Orbital Cellulitis - Causes
A
- Spread of remote infection
- Sinus infection (most common)
- Mid-facial infection
- Dental infection
- Post-trauma (2-3 days after)
- Post-surgical
43
Q
Orbital Cellulitis - Signs and Symptoms
A
- Much ‘angrier’ set of symptoms than preseptal
- Swollen, red, warm and tender eyelids
- PROPTOSIS
- Restricted and painful eye movements
- ON dysfunction (advanced)
- Pupil reactions - if very severe, direct response likely reduced, if less severe, more commonly RAPD in affected eye
- VA
- Colour vision
- Rapid onset (hrs)
- Severe malaise & fever
44
Q
Orbital Cellulitis - Management
A
- CMG: “Emergency (same day) referral to ophth or A&E, no intervention”
Treatment by ophth:
- Confirmation of diagnosis, CT scan, blood tests
- Admission to hospital
- Systemic antibiotics (IV)
45
Q
Preseptal vs Orbital
A
Preseptal Orbital
Proptosis Absent Present
Motility Normal Painful, restricted
VA Normal Reduced in severe cases
CV Normal Reduced in severe cases
RAPD Normal Reduced in severe cases
