NEURO-OPHTHALMOLOGY,Clinical Examination,Visual Acuity Colour Vision Visual Fields Pupils,Normal Eye and Optic Disc,Cupped disc,The swollen optic disc,Papilloedema Papillitis Malignant hypertension Ischaemic optic neuropathy Diabetic optic neuropathy CRVO Intraocular inflammation,25 y.o. female Reduced VA Pain with eye movement Colour desaturation RAPD,65 y.o. male Reduced VA Painless loss of vision Essential hypertension Smoker,The pale optic disc,Congenital Secondary to raised ICP vascular retinal disease optic neuritis optic nerve compression trauma Glaucoma,Papilloedema,Disc swelling secondary to raised ICPHeadache Worse in the morning Valsalva manouver Nausea and projectile vomiting Horizontal diplopia (VI palsy) Causes Space occupying lesion Intracranial hypertension Idiopathic Drugs Endocrine Severe hypertension,Haemorrhages,CWS,Blurred optic disc margin,Small optic cup,Disc pallor,Vessel attenuation,Pupils,First Order Retina to Pretectal Nucleus in B/S(at level of Superior colliculus) Second Order Pretectal nucleus to E/W nucleus(bilateral innervation!) Third Order E/W nucleus to Ciliary Ganglion Fourth Order Ciliary Ganglion to Sphincter pupillae (via short ciliary nerves),Pupil,Constricted (mioisis) Sympathetic (pupillodilator) denervation Drugs Pilocarpine Morphine,Dilated (mydriasis) Parasympathetic (pupilloconstrictor) denervation Lesion of the third CN DrugsAtropine Cocaine,Horners,Oculosympathetic paresisPtosis Miosis Ipsilateral anhidrosis Does not dilate with cocaine 4%,Sympathetic Pathway,First Order Posterior Hypothalamus to Ciliospinal centre of Budge (C8-T2)(Uncrossed in Brainstem) Second Order Ciliospinal centre of Budge to Superior Cervical Ganaglion Third Order Superior Cervical Ganglion to dilator pupillae muscle. (Close to ICA and joins V1 intracranially),Pancoast bronchogenic carcinoma,Otitis Media Tolosa-Hunt Sy.,CVA Tumour,Internal Carotid Dissection,Herpes Zoster,Causes of Horners pupil,Central B/S lesions (tumours, vascular and MS)Syringomyelia, Lat. Med. Syn., S.C. ca. Preganglionic Pancoast tumour, Carotid & Aortic aneurysms, Neck lesions/trauma. Postganglionic Cluster headaches, Nasopharyngeal tumours, Otitis media, Cavernous sinus mass and ICA disease. Miscellaneous Congenital (brachial plexus injury)Idiopathic.,Argyll-Robertson pupil Small, irreg Does not react to light Reacts to accommodation Causes syphilis diabetes,Miotonic pupil (Adies syndrome) Dilated Poor response to light and convergence. Constricts with weak Pilocarpine Holmes-Adie syndromeReduced tendon reflexes (Knee, ankle) - Orthostatic hypotension,Afferent & efferent defects,Ocular motility abnormalities,Third nerve palsy Double vision Eye turned down & out Ptosis Dilated pupil & headache Compressive lesion,Sixth nerve palsy Double vision Eye turned in,Cranial Nerve Palsies,Looking straight ahead,Posterior communicating artery aneurysm,III CN,Posterior cerebral artery,Chiasma,Internuclear Ophthalmoplegia,Defective adduction of the ipsilateral eye Nystagmus of the contralateral (abducting) eye NORMAL CONVERGENCE Causes Young patients Bilateral Demyelination Older patients Unilateral Vascular, tumours,Myasthenia Gravis,Fatigability Double vision Lid twitch Ptosis Normal reflexes & sensation,INVESTIGATIONS MG,Anti ACh receptor Abs Electromyography Tensilon test Edrophonium blocks acetyl-cholinesterase Beware of cholinergic cardiac effects. Use with Atropine 0.6mg Thoracic CT and MRI to rule out thymoma,Anti AChR Abs,AChR,ACh,Localising the lesion,Monocular visual field defects indicate lesions anterior to the optic chiasm Bitemporal defects are the hallmark of chiasmal lesions Binocular homonymous hemianopia result from lesions in the contralateral postchiasmal region Binocular quadrantanopias reflect optic tract lesions,