Ophtha 250 [5]: Ophthalmology and Visual Sciences 1

Lec 04: Neuro-Ophthalmology

Raul Cruz, MD October 13, 2014

TOPIC OUTLINE
 Confrontation test
o Subjective
I. Visual acuity testing
o Reliable if done properly
II. Visual field testing
o Targets:
III. Visual pathway
 Hand movement
IV. Visual field defects
 Finger counting
V. Pupillary reactions
 Objects (light, red targets)
VI. Ocular motility testing
 Face to face
VII. Ophthalmoscopy

Objectives
1. Know the basic neuro-ophthalmic examination.
2. Recognize and interpret common signs of neuro-ophthalmic disorders.

Note: This is a “new” lecture for Ophtha 250 AY2014-2015. No previous transes
from 2015 and 2016 are available. First rotating in as Ophtha ICCs is Block 5-Star
of 2017.

INTRODUCTION Figure 3. Amsler grid

 The EYE is a window to the CNS  Amsler grid is a rapid screening test used to detect central visual
field defects
“30% of sensory fibers entering the brain are via the optic nerves;
60% of intracranial diseases exhibit neuro-ophthalmological signs”

 If a patient presents with visual problems, one must distinguish

whether it is due to a subnormal vision or an optic nerve disorder.

VISUAL ACUITY TESTING

 Do a pinhole test to eliminate errors of refraction

 Important step in visual acuity testing:
o Far vision – Snellen’s chart
o Near vision – Jaeger’s chart (alternative: Telephone directory or
white pages)
Figure 4. Conditions detected using Amsler grid. (left)
Metamorphopsia – a retinal defect; (right) Central scotoma – an optic
VISUAL FIELD TESTING nerve defect

 Visual field comprises all the space that can be seen at a given
instant with the eye fixating directly ahead
 Visual field exam gives valuable information about the localization of
the disorder along the visual pathway
 Largest field of vision: lateral side

Figure 5. Automated perimeter

 Automated perimetry
o Objective
o Eliminate errors
o No bias by perimetrist
o Randomized stimulus
o Greater sensitivity
o Detects early field loss
o Results are reproductible
o Store results
Figure 1. Visual field testing
VISUAL PATHWAY
 Types of visual field testing:
o Subjective
 Confrontation test
 Amsler grid
o Objective
 Perimetry

Figure 6. The visual pathway. (arrows from right to left) Retina  Optic
Figure 2. Confrontation test Nerve  Optic Chiasm  Optic Tract  LGB  OR  Occipital Cortex

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 Lec 04: Neuro-Ophthalmology Ophtha250

o When light is moved from the good to the abnormal eye, pupil
 Pre-Chiasm dilates instead of constricting
o Retina o Seen in optic nerve lesions
o Optic Nerve
 Chiasm  Swinging Light Test procedure
o Optic Chiasm o Dark room – pupils will be maximally dilated
 Post-Chiasm o Bright stimulus – pupils will be maximally constricted
o Optic Tract o Fixate at a distance – to avoid constriction due to
o Lateral Geniculate Body accommodation
o Optic Radiation o Light moved from eye to eye
o Occipital Cortex
o Calcarine fissure
 Divides the two occipital cortices

VISUAL FIELD DEFECTS

 Scotoma – abnormal blind spot in the field of vision

o Central
o Cecocentral
o Paracentral
o Arcuate
o Hemianopia
o Quadrantanopia
o Homonymous
o Congruous – same kind and shape

Figure 9. Pathway of pupillary constriction

Figure 7. Types of visual field defects

Figure 10. Pathway of pupillary dilatation

 Anisocoria – asymmetry in pupil size which may be due to

unilateral disorders of the autonomic systems
o Constricted
 Sympathetic lesions – Horner’s syndrome
o Dilated
 Parasympathetic lesions – Adie’s pupil, CN3 paralysis
o Pharmacologic causes
 Dilatation: atropine
 Constriction: glaucoma medications

OCULAR MOTILITY TESTING

Figure 8. Visual field defects and possible site of lesion along the
optic tract

PUPILLARY REACTIONS

 Pupillary control is the balance between the parasympathetic

(constrict) and the sympathetic (dilate) system
 Pupillary exam
Figure 11. Extraocular muscles and eye movements
o Check for anisocoria – direct and consensual reflex
o Swinging Light Test – rapid, sensitive, inexpensive, reliable,
objective test of detecting unilateral optic nerve disorder  EOM innervations
 Elicits a relative afferent pupillary defect (RAPD) or a Marcus o CN3: SR, IR, IO, MR, levator palpebrae superioris, pupillary
Gunn pupil – seen in optic nerve diseases, also in extensive constriction, accommodation
retinal diseases (CRAO, retinal detachment) o CN4: SO
o CN6: LR
 RAPD  CN3 paralysis
o Elicited by swinging light test o Downward and outward deviation
o Less light stimulus is transmitted to the defective eye o Diplopia
o Ptosis

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 Lec 04: Neuro-Ophthalmology Ophtha250

o Dilated pupil  Causes of optic disc edema

o No accommodation o Papilledema
 CN3, 4 or 6 disorder – result in misalignment and diplopia o Inflammatory
o CN3: outward and downward o Vascular
o CN4: upward, head tilt o Toxicity
o CN6: inward o Infiltrative
o Medications
o Demyelinating
o Traumatic
o Compressive
o Nutritional
o Infectious
o Hereditary

Figure 12. Common etiologies of CN3, 4 and 6 disorders

OPHTHALMOSCOPY

 Ophthalmoscopy evaluates:
o Optic Nerve
o Vasculature
o Macula
o Retina
 Normal findings in funduscopy
o Clear media, (+) ROR
o Optic disc – pinkish, distinct
o C/D – 0.3 or 0.4 Figure 15. Progression of optic disc edema. Note the loss of disc
o A:V – 2:3 or 3:4 borders until the hemorrhages
o No hemorrhages, no exudates
o Spontaneous venous pulsations  Optic disc atrophy – end result of diseases or injuries to the optic
nerve
o On funduscopy, the disc will be very pale in color (light pink, light
yellow)

Figure 13. Normal VS abnormal funduscopic findings

 Any injury, trauma, ischemia, infection, or toxicity, to the optic nerve

can cause swelling of the axons resulting in edema and elevation
of the optic disc
 With optic disc edema, always consider papilledema because it is
life threatening
 Papilledema – associated with increased intracranial pressure,
associated with tumors
o Disc swelling, increased ICP
o Optic nerve is surrounded by meninges
o ICP is transmitted to SAS surrounding optic nerve
o Cause: space-occupying lesion obstructing flow of CSF Figure 16. Optic disc atrophy

END OF TRANSCRIPTION

FMAC: ang bilis ng panahon! :)) ang daming nangyayari! Pero kakayanin lahat! Go
team!

#Block5Star #ReignSupreme!
#OneUPCM #ParaSaBayan
Padayon Medisina.
Boom #PaMED!

Before MU, Doctors Dreamed.

AFTG! TINGWOT!

MANDERKS: hi block 5 star!! First legit ICC rotation.. haha!! Sama sama tayo
through thick and thin sa rotations.. kayang kaya!!

Figure 14. Funduscopic findings in papilledema. Bilateral; indistinct 2017, support din natin ang trp!! Ilang days na lang, kelangan na nating magtriple
disc borders; hyperemic, swollen disc; obliterated central cup; venous effort para malagay din ung class natin sa perpetual trophy.. hehe..
distention; hemorrhages; exudates; cotton wool spots; no spontaneous
venous pulsations Hi din sa mga groups!! And sa newly clingy management group!! Whohoo!! :D

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Appendix A: PRE-TEST

Test: visual field test

Findings: bilateral cecocentral scotoma
LEFT eye

Test: visual field test

Finding: homonymous hemianopsia with macular sparing
Right: RIGHT eye Left: LEFT eye
C/D: 0.6 (>0.3-0.4) – may be present in patients with glaucoma

Papilledema – indistinct disc borders, hyperemic swollen discs,

Describe: shorter arrows in the diagram at left side
obliterated central cup, venous distention, hemorrhages, exudates,
Findings: limited range of motion for SR, IR, and LR
cotton wool spots
Right EYE: problem with range of motion Left EYE: normal

Optic disc atrophy – very pale disc, borders indistinct

Lateral rectus (LR) palsy – CN6 disorder

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Appendix B: SOME TYPES OF VISUAL FIELD DEFECTS

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