Suba and Elle

Proving neuro ophthalmology is fun. Please follow, like and comment with questions. Personal opinions, doesn’t replace medical advice. © 2021 – 2024.

[Suba and Elle @NeuropticEd]

Most patients with #IIH never require #surgery, but if severe / refractory, there are multiple surgical options (the 4 Ss) – Sheath fenestration, #Shunting, Sleeve surgery (or other #weight loss surgery), and Sinus #stenting.

#MedEd #neurology #ophthalmology

[Suba and Elle @NeuropticEd]

Foster Kennedy syndrome: unilateral #optic disc #oedema with contralateral optic disc #pallor, can be from a lesion, but also ischaemic optic #neuropathy and other causes.

#MedEd #Neurology #Ophthalmology

[Suba and Elle @NeuropticEd]

#Frisen grading of disc oedema

0: No disc oedema
1: Blurred nasal margin
2: Circumferential blurring of optic nerve
3: Obscured blood vessels AROUND optic disc
4: Obscured blood vessels ON optic disc
5: All vessels obscured on optic disc +/- haemorrhages

#MedEd #ophthalmology

[Suba and Elle @NeuropticEd]

#MOG and #AQP4 are two possible causes of antibody mediated #opticneuritis. AQP4 tends to be less responsive to therapy and cause more severe vision loss, with more #astrocyte damage. A few other common differences are highlighted here.

#MedEd #NMO #Neurology #Ophthalmology

[Suba and Elle @NeuropticEd]

Vitamin B12/folate deficiency -> bilateral optic neuropathy -> bilateral painless progressive vision loss, caeocentral scotoma. Dietary history is important for bilateral subacute vision loss

Also look for peripheral neuropathy, anaemia, cognitive/gait impairment, and glossitis

[Suba and Elle @NeuropticEd]

Papilloedema is the most common finding in IIH, but changes can also be seen in the retina. Choroidal folds, peripapillary wrinkles, and intraretinal folds all affect different layers and areas of the retina.
Seen best on OCT and also resolve with treatment of IIH.

#MedEd

[Suba and Elle @NeuropticEd]

Refractive error/dry eyes -> abnormalities in anterior eye -> blurred vision/monocular diplopia.

Pinhole occluder removes aberrantly directed light and corrects for anterior eye abnormalities – any symptoms that completely improve with pinhole occlusion is not neuro ophthalmic.

[Suba and Elle @NeuropticEd]

Sarcoidosis is a multi-system inflammatory granulomatous disease. The ophthalmic and neurologic manifestations make SARCOID:

Snowballs (vitreous)
Anterior/posterior uveitis
Retinal vasculitis
Cranial neuropathy (often CN VII)
Optic neuritis
Iris nodules
Demyelinating lesions

[Suba and Elle @NeuropticEd]

When assessing constricted visual fields, check visual fields at near and distance.
Functional vision loss: same constriction at near and distance (‘tunnel’ vision)
Organic vision loss: see wider field at distance (‘funnel vision’)

#MedEd #vision #ophthalmology #tunnel #funnel

[Suba and Elle @NeuropticEd]

Kearn-Sayre syndrome is a mitochondrial myopathy typically manifesting with CPEO, pigmentary retinopathy and cardiac conduction defects. Age of onset is typically < 20 years old, and the diagnosis can be confirmed with the appearance of ragged red fibres on muscle biopsy.

#MedEd

[Suba and Elle @NeuropticEd]

Kearn – Sayre

K(cardiac conduction)
External ophthalmoplegia (CPEO)
Ataxia (cerebellar)
Ragged red fibres
Neuromuscular disorder

Sugar (diabetes)
Adrenal insufficiency
Yelling (hearing impaired)
Retinopathy (salt/pepper fundus)
Endocrine (short (growth deficiency), low PTH)

[Suba and Elle @NeuropticEd]

Functional vision loss does not have a localisable structural cause. There can be incongruous features on examination suggesting vision that the patient may not actively experience, or deficits that are not vision based (touching fingers is a test of proprioception).

#MedEd

[Suba and Elle @NeuropticEd]

Convergence spasm, spasm of the near reflex, manifests as intermittent prolonged episodes of convergence (bilateral adduction (convergence), miosis, accommodation).

Often confused with CN 6 palsy, or MG - check for miosis.

Rx: try atropine, lenses, occlusion, Botox, surgery

[Suba and Elle @NeuropticEd]

Enhanced ptosis / 'curtain' sign can identify bilateral ptosis where there is asymmetry, and the milder #ptosis might otherwise be missed. Manually elevating the more affected eyelid can unmask the other eye ptosis. This can be a sign of #MG / #LEMS.

#MedEd #Neurology

[Suba and Elle @NeuropticEd]

Proptosis: abnormal protrusion of one or both eyes. Definition (> 18mm or asymmetry of 2mm) depends on ethnicity. #TED is the most common bilateral cause. Where unilateral, urgent workup for more sinister causes such as arteriovenous fistulas should be considered.

#MedEd #Neuro

[Suba and Elle @NeuropticEd]

Ocular neuromyotonia: recurrent involuntary tonic muscle spasm of one or more EOMs -> intermittent binocular diplopia ~few min
Usually CN III / VI

Associated with RTx/TED/sellar/parasellar disease.

For more info, we wrote this review (shameless plug): https://t.co/5aj7Uawytc

[Suba and Elle @NeuropticEd]

Saccades, rapid eye movements from one target to another, require stimuli and activation of a cascade of pathways. Abnormal horizontal saccades can therefore result from abnormalities in any of these locations.
#MedEd #Neuroanatomy #Ophthalmology

[Suba and Elle @NeuropticEd]

#VEP reflects visual cortex responses to visual stimuli.

Abnormal visual pathway (eg. optic neuropathy) maybe cause slower (prolonged latency) or smaller (lower amplitude) response or both.

Drowsiness, functional vision loss, not wearing glasses can cause abnormal VEPs

#MedEd

[Suba and Elle @NeuropticEd]

Posterior staphyloma: abnormal outpouching of the sclera. From Greek staphylus - ‘cluster of grapes’, reflecting it’s appearance.

Most common in myopic eyes but can be associated with trauma, infection and systemic diseases.

B-scan and OCT may help define it further.

#MedEd

[Suba and Elle @NeuropticEd]

Optic tract lesions cause contralateral homonymous hemianopia. The contralateral side (temporal VF loss) has bow tie atrophy (nasal/temporal optic disc thinning) while the ipsilateral side (nasal VF loss) has hourglass atrophy (superior/inferior optic disc thinning)

#MedEd