2. History
• Loss of vision
• Diplopia
• Eye pain
• Eyelid drooping (ptosis)
3. Key Aspects of the
Examination
• Visual acuity
• Color vision Pupils : size and reaction in light
and dark
• Extraocular motility
• Lids
• Visual fields
9. Vision Loss
• Monoculr or binocular
• Key is localization (refractive
, retina or optic nerve)
• Visual acuity assessment
with pinhole. (refractive)
• Look for RAPD .
• Metamorphopsia .
• Visual fields.
10. Case
• A 70 year old woman with sudden loss of
vision in the right eye.
• Transient loss of vision and jaw pain.
• Feeling unwell lately with, and loss of
appetite ( 10 Kg) , malaise and myalgias.
• Hypertension on Metoprolol.
• Visual acuity: Count finger right , 20/30 left.
• Pupils : Right RAPD.
13. Temporal Arteritis
• Systemic vasculitis (Aortitis in 20% consider
PET/MRA).
• New onset of headache (temporal) , acute or
transient loss of vision, jaw claudication, weight loss,
fever, and myalgias.
• Age usually over 60.
• Occult GCA ( No systemic symptoms, transient
diplopia or transient visual loss).
• A true neuro-ophthalmic emergency (54-95%
second eye involvement if untreated) !
15. GCA Visual loss
Management
• Stat ESR , CRP and CBC (platelets).
• CRP and CBC have 97% sensitivity and specificity.
• Start high dose systemic steroids (IV or Oral)
immediately upon suspicioun ( AAION or CRAO
can develop in fellow eye within days if untreated !)
• Arrange for temporal artery biopsy within 2 weeks ,
while patient is on steroids.
16. Case
• 52-year-old previously healthy presents
with severe headache and blurred vision in
both eyes.
• Visual acuity 20/80 OD and 20/60 OS.
• Confrontation visual fields : Bitemporal
Hemianopia.
20. Pituitary Apoplexy
• “Worst headache in my life”.
• Visual field loss, and/or ophthalmoplegia ( uni- or
bilateral).
• Patients usually present 2 weeks after ictus.
• > 80% did not have history of pituitary tumor
• Life threatening (hypotension, shock) because of
hypo-pituitarism, and low cortisol levels, and
diabetes insipidus.
21. Case
• A 52 year old man with blurred vision
and mild headache for the last 6 weeks.
• Headaches are severe 10/10 scale ,
worse in the morning and leaning
forward.
• Visual acuity : 20/20 OU
25. Papilledema
• Bilateral disc edema due to raised ICP.
• Normal visual acuity.
• Visual fields : enlarged blind spots
(early)
26.
27. Malignant
Hypertesnion• Accelerated hypertension with target
organ damage.
• Papilledema must be present for
diagnosis !
• Dysfunction of cerebral blood flow
autoregultaion causing cerebral edema.
• Pre-eclampsia .
• Encephalopathy can be present.
28. Evaluation of Diplopia
• Mono-ocualr or bin-ocular .
• Orientation of images (vertical , horizontal , oblique)
• Associated signs and symptoms (pain , loss of vision)
• Follow-my-finger exam may not be enough !
• Maddox-rod or cover-uncover test .
• Always check the eyelid and pupil !
29. Case
• 78 year old man with acute diplopia,
and headache.
• Headache and nausea .
• Diabetes, hypertension, atrial
tachycardia.
• Limitation in adduction , elevation and
depression in the right eye.
30.
31.
32.
33. Pupil-involving 3rd Nerve
Palsy
• Posterior communicating artery
aneurysm, or mass.
• Appropriate neuro-imaging is
(MRI/MRA, MRI/CTA, Angiogram is the
gold standard for aneurysm detection).
• CTA is better for detecting aneurysms.
• MRI is better to rule out masses .
34. Risk of Aneurysm and
“Rule of Pupil”
Ophthalmoplegia Pupil Aneurysm Risk
Complete/Partial Complete 86%-100%
Partial Spared 30%
Complete Spared very low
If signs of sub-arachnoid hemorrhage present (headache, photophobia,
35.
36. Anisocoria
• Acute onset vs acute awareness .
• Associated symptoms (headache , neck pain , eye
pain)
• Is the anisocoria worse in the dark or light ?
• Pharmacologic testing and neuro-imaging aid in
localization.
37. • A 67 year old man presents with pain in his right eye
for 5 days associated with neck pain after
chiropractic treatment.
• Hypertension and ischemic heart disease on
treatment.
• No double vision.
• VA : 20/30 OU.
• Right partial ptosis (1 mm with right pupil smaller
then left more in dark than light)
Case
39. Evaluation of
Horner’s• Misois, and ptosis (upper and lower lid).
• Dilatation lag, anisocoria worse in dark.
• Topical Cocaine test-> Horner’s pupil
will not dilate (Greater Anisocoria)
• Hydroxyamphetamine test – distinguish
pre- from post-ganglionic
• Apraclonidine Reversal of
Anisocoria.
40. Acute Horner’s
Syndrome
• Painful Horner’s syndrome is a
neurologic emergency.
• Although can be seen in many types of
headaches (Cluster, Migraine etc).
• Rule out ICA dissection.
• MRI/MRA of the head/neck/upper
mediastinum is indicated.
43. ICA dissection
• Goal is to prevent secondary neurologic
deficit (stroke).
• Anti-coagulation.
44. Acute Proptosis
• Associated ocular symptoms (pain , diplopia , loss of
vision).
• Associated systemic symptoms (fever , malaise , loss
of weight , excessive sweating , tremor or palpitations
)
• Past Medical History : Thyroid eye disease , diabetes
, immunocompromised , recurrent sinusitis , recent
tooth extraction )
45. • A 55 year old woman with with painful proptosis in
the left eye .
• Medical History : Rheumatoid Arthritis treated by
NSAID.
• Visual acuity : 20/20 Both eyes.
• Anterior Segment : Conujnctival hyperemia
• Exophthalmometry : 24 mm and 20 mm OS
• Normal pupils, ocular motility and fundus
examination.
Case
48. Graves Disease
• Female with underlying thyroid disease .
• Typically bilateral but can be unilateral.
• Lid retraction , lid lag , and chemosis .
• CT : extraocular muscle enlargement ,
fat expansion .
50. Treatment
• Medical : tears and cold compressors ,
IV Steroids, Rituximab.
• Surgical (inactive phase) : Orbital
decompression , strabismus surgery ,
eyelid repositioning , Blepharoplasty .
• Orbital radiation
51. Orbital Inflammatory
Disease
• Males = Females
• Acute onset , no eyelid
lag or retraction .
• CT : enlarged and
irregular muscles , often
unilateral.
• Can be associated with
systemic disease (SLE ,
Crohn’s , GPA ,
Rheumatoid Arthritis).
54. Orbital Cellulitis
•Fever and leukocytosis ,
patient is ill.
•Sinusitis , dacryocystitis,
dycryoadenitis.
•Less common is trauma or
endogenous spread.
•Beware in diabetes mellitus
and immunocompromised
patients (mucormycosis) !
57. Orbital Cellulitis
• Treatment : IV antibiotics , anti-fungal
agents.
• Close monitoring for complications
(intracranial extension , or cavernous
sinus involvement)
• Additional debridement : Mucormycosis,
Necrotizing Fasciitis.
• ENT consultation for drainage of sinuses
(FESS) or abscess drainage .
58. Conclusion
• Appropriate history and systemic examination is key
in diagnosing neuro-ophthalmic emergencies .
• Acute loss of vision in an elderly patient should raise
the suspicion of Giant-Cell Arteritis .
• Pupil-involving third nerve palsy can be the
presenting sign of an intracranial aneurysm.
• Acute painful anisocoira can be due to internal-carotid
artery dissection .
• Acute proptosis is in diabetic or immunocompromised
patients can be due to life-threatening fungal orbital
cellulitis .
