Neuro-oph and orbit Flashcards
Ddx for anomalous nerve with double ring sign
- Optic nerve hypoplasia:
- Can be assoc with CNS defects or can be isolated
- if CNS abnormalities = septo-optic dysplasia (DeMorsier Syndrome)
- warrants neuroimaging to look for absence of septum pellucidum and/or corpus callosum (if present –> endocrine eval)
- Optic atrophy
- Optic nerve coloboma
- Optic nerve pit
Ddx for optic disc edema
Optic disc drusen
Papilledema
Papillitis
Chronic disc edema
Work up:
Check both eyes to see if bilateral
Full eye exam (VA, IOP, color plates, rapd? VF defects?)
Bscan looking for drusen (or CT orbits or autofluorescence on FA)
B scan finding: optic nerve echogenicity even at low gain
Ddx for abnormal disc vessels that appear to be opto-ciliary shunts.
- any chronically compressed optic nerve lesion
- optic nerve glioma - kid
- optic nerve sheath meningioma - middle aged woman
- chronic papilledema
- prior CRVO
Ddx for corkscrew conjunctival vessels. Work up?
Carotid cavernous fistula
Conjunctivitis
Episcleritis
Work up: history of htn, preceding trauma to head, whooshing sound. (low grade fistula in htn, high grade in trauma)
No mucopurulent discharge, measure bp. perform eye exam VA, IOP, color vision, Hertel and EOM. auscultate for bruit. slit lamp looking for exposure.
Get CT orbit with contrast looking for enlarged superior ophthalmic vein (or CTA)
Ddx for left hypertropia worse on left head tilt.
- CN4 palsy - congenital, microvascular, acquired (trauma)
- Thyroid eye disease
- Myasthenia gravis
- Skew deviation - MS or stroke
Work up: full eye exam–
if exam suggests involvement of multiple cranial nerves get neuroimaging
all patients under 45 with no hx of trauma, vasculopathy, negative photo history, get neuroimaging
Ddx of left eye which does not abduct in left gaze. Work up.
- 6th nerve palsy - congenital or acquired (trauma, increase in icp, microvascular, vaccination, infectious)
- Thyroid eye disease
- Orbital fracture of orbital wall causing restrictive strabismus
- Idiopathic orbital inflammation (IOI)
- Giant cell arteritis (GCA)
Work up: history of DM, htn, TED, GCA ROS. check bp and get labs.
Ddx of left nerve palsy involving upper and lower face.
- Bell’s palsy (diagnosis of exclusion)
- Cerebellopontine mass (tinnitus, vertigo, hearing loss, nystagmus)
- Trauma (temporal bone fracture)
- Facial lac/iatrogenic (parotid surgery, facial n. block)
- Infection (Lyme, otitis, Ramsy hunt, gauillan barre, syphilis)
- Infiltrative (sarcoid, mets, collagen vascular disease)
- Cancer (nasopharyngeal, parotid)
- Vasculopathic (GCA, DM)
Ddx of left ptosis and left anisocoria (left pupil smaller than right)
- Horner’s syndrome - acquired or congenital
- 3rd nerve palsy (does not cause miosis)
- Iritis
- Medication (topical mydriatic miotics, oral pseudoephedrine)
- trauma or physiologic
Ddx for 1st, 2nd, 3rd order Horners
1st order: stroke, MS, brain tumor, vertebrobascilar insufficiency
2nd order: tumor of lung (apical Pancoast tumor), metastasis, neuroblastoma, lymphoma
3rd order: migraine, carotid dissection, herpes zoster, Tolosa hunt, trauma, forceps injury
Ddx for bilateral disc edema, hemorrhages, venous engorgement.
- Papilledema due to intracranial mass
- Papilledema due to venous sinus thrombosis
- IIH (idiopathic intracranial hypertension)
- Bilateral papillitis (diabetic papillitis, optic neuritis, uveitis, leukemic infiltration)
- Compressive optic neuropathy (Thyroid Related Ophthalmopathy, or IOI)
- Malignant hypertension
Work up of bilateral optic disc edema with hemorrhages.
History of headaches that are positional worse with lying down, pulsatile tinnitus, TVO, obesity, recent weight gain, tetracycline abx or hormonal meds.
Check BLOOD PRESSURE (rule out malig htn)!!!
Eye exam: VA, IOP, APD if asymmetric, pain with eye movements, Color vision, Confrontation VF, EOMs, RRP (resistance to retropulsion), Slit lamp exam looking for evidence of uveitis. Would not expect to see spontaneous venous pulsations in IIH.
Order CBC, ACE, lysozyme, CT chest, FTA-Abs, quant gold. if normal – get MRI to assess for intracranial lesion and MRV to assess for venous sinus thrombosis.
If no space occupying lesion – get LP with opening pressure and send for cytology and CSF study
What is the ddx for proptosis in an adult?
Orbital cellulitis Orbital pseudotumor (IOI) Orbital and lacrimal gland tumors Orbital vasculitis Trauma AV fistula Cavernous sinus thrombosis
What is a junctional scotoma? And what is the ddx for it?
Visual field defect showing central scotoma in affected eye and superior-temporal VF defect respecting vertical in the fellow eye.
*Caused by lesion of optic nerve near the CHIASM
Ddx: Chiasmal mass lesion or possibly due to hemorrhage *Tumors *pituitary apoplexy *aneurysm *trauma *sarcoidosis *chiasmal neuritis
Get neuroimaging and endocrine evaluation (check hormone levels)
What is ddx for transient diplopia?
Most common:
- Myasthenia gravis
- Decompensated phoria
- Convergence or divergence insufficiency
Others:
- GCA
- Vertibrobasilar insufficiency
- Superior oblique myokymia
- Skew deviation
- Cyclic esotropia
What is important to rule out when you suspect Myasthenia Gravis?
RULE OUT: thyroid disease, thymoma, other autoimmune disorders.
Get TFT, ANA, RF, chest CT or MRI scan
