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Neuro-Ophthalmologic Disorders

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Nystagmus

• An involuntary rhythmic eye movement
• Patient is usually unaware that it’s happening, but may have blurred vision

Causes

• Congenital neurological problem
• Trauma
• Stroke
• Multiple Sclerosis
• Inner ear inflammation
• Alcohol
• Sudden head movements
• Looking out a train window
• etc

Clinical Presentation

• Dizziness/Vertigo
• N/V
• Involuntary rhythmic eye movement
  • Up and down
  • Side to side
  • Rotary

Labs, Studies and Physical Exam Findings

• Clinical diagnosis
• Eye exam
• MRI/CT checking for a mass effect

Treatment

• Observation
• Gabapentin
• Glasses/contacts may help improve overall vision
• Surgery

Optic Neuritis

• An inflammation of the optic nerve
• Usually unilateral
• Most commonly found 20-40 year olds

Causes

• Autoimmune is the number
  • Multiple sclerosis is #1 cause and optic neuritis is the most common presenting sign of MS
  • Scleroderma
  • Lupus
• Fungal infection
• Bacterial infection
  • Lyme
  • TB
  • Syphilis
• Viral infection
  • Herpes zoster
  • Mumps
  • Rubella
  • Epstein Barr
• Vitamin B deficiency

Clinical Presentation

• Acute vision loss or blurred vision
• Loss of color vision
• Pain often occurring before the visual symptoms
• Pain with eye movement

Labs, Studies and Physical Exam Findings

• Visual acuity test (acuity is decreased)
• Color vision test (loss of color)
• MRI of the brain
  • May show optic neuritis
  • May help diagnose MS

Treatment

• Treat the underlying cause
• Observation
  • Without underlying disease most cases resolve on their own within three months
• IV steroid may be used

Papilledema

• Swelling of the optic disc secondary to increased intracranial pressure

Causes

• Encephalitis
• Meningitis
• Brain tumor
• Brain abscess
• Hemorrhage

Clinical Presentation

• Nausea and vomiting
• Headache
• Vision may have any of the following
  • Normal
  • Flickering
  • Double vision
  • Blurred vision

Labs, Studies and Physical Exam Findings

• Ophthalmoscope
  • Swollen optic disc
• Increased size of blind spot
• MRI or CT needs to be done immediately
• Lumbar puncture once a brain mass has been ruled out

Treatment

• Treat the underlying cause of increased intracranial pressure

Orbital Disorders

Orbital Cellulitis

• An infection of the eyelid and skin around the eye
• More common in children than adults

Causes

• Strep pneumonia
• Staph aureus
• Haemophilus influenzae
• Often orbital cellulitis is secondary to a chronic sinus infection or a dental infection

Clinical Presentation

• Painful swelling of the eyelid and tissue surrounding the eye
• Vision problems
• Eye pain with motion
• Purulent discharge
• Fever, lethargy
• Shiny red eyelid
• Difficulty opening the eye

Labs, Studies and Physical Exam Finding

• CBC
• Blood culture
• Gram stain and culture of discharge
• X-ray of the sinuses
• CT/MRI of the sinuses

Treatment

• Patients will usually be admitted for IV antibiotic therapy cover Staph and Strep and H.
  • Vancomycin
  • Ceftriaxone
  • Imipenem
• Surgical intervention may be necessary for an abscess

Retinal Disorders

Retinal Detachment

Risk Factors

• Myopia (near sighted)
• Cataract surgery
• Trauma
• Family history

Clinical Presentation

• Sudden vision loss, central vision goes last
• “Curtain coming down”
• Painless

Labs, Studies and Physical Exam Findings

• Fundoscopic exam
  • Retina may appear to be hanging
  • Asymmetric red reflex

Treatment

• REFER!
• Use gravity in an attempt to keep retina in place
  • Pt lays supine and turn head toward symptomatic side
• Surgery
• Most uncomplicated cases due well

Retinopathy

• Damage to the retina

Causes

• DM – DM Type 1 screen annually, DM type 2 screen every 3-5 yrs
• HTN
• Premature at birth
• Radiation damage – pain usually 6-12 hours after exposure – think sunburn of the eye
• Sickle Cell

Clinical Presentation

• Painless
• Vision loss or changes
• Vision changes don’t typically occur until late in the disease process. Routine exams are important to pick it up early.

Labs, Studies and Physical Exam Findings

• Fundus exam
  • DM
    • Non proliferative
      • Hemorrhages
      • Exudates
      • Cotton wool spots
    • Proliferative – develops after non proliferative
      • Neovascularization
      • Edema
  • HTN
    • Arteriolar narrowing
    • Arteriosclerosis
      • Copper wire
      • Silver wire sclerosis
      • Arteriovenous nicking
      • Flame hemorrhages

Treatment

• Treat underlying disorder
• Radiant energy burn – analgesics, maybe an antibiotic ointment
• Refer to ophthalmology

Macular Degeneration (Age Related Macular Degeneration)

• Typically affects people older than 50
• ARMD begins with yellow deposits of debri called drusen into the macula
• The two types of ARMD are dry (atrophic) and wet (neovascular)
• Dry occurs first and 10-15% of cases will process to wet.

Risk Factors

• Age
• Family history
• Smoking
• HTN

Clinical Presentation

• Painless
• Loss of central vision (scotoma)
• Wavy vision (metamorphopsia)
• Decrease in visual acuity

Labs, Studies and Physical Exam Findings

• Test visual acuity
• Amsler grid for metamorphopsia
• Drusen deposits
• Atrophy of the retina – pigment loss

Treatment

• Laser photocoagulation
• Dietary supplements including vitamin A,C, E B6, B12, zinc copper, lutein omega 3 fatty acids
• Wet ARMD
  • Vascular endothelial growth factor inhibitors must be an intravitreal injection (yikes!)
    • ranibizumab
    • pegaptanib
    • bevacizumab

<< Click here to get 23 ENT questions straight from my book, The Final Step >>