Neuro – Ophthalmology

For diagnosis and treatment of inter-related disorders of the eye and neurological system.

What is Neuro-Ophthalmology?

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Neuro-ophthalmology is an ophthalmic subspecialty that addresses the relationship between the eye and the brain, specifically disorders of the optic nerve, orbit, and brain, associated with visual symptoms. Neuro-ophthalmologists provide comprehensive clinical care to a broad spectrum of patients with visual disturbance from optic nerve diseases, central nervous system disorders, ocular motility dysfunction, and pupillary abnormalities.

This is the most common cause of sudden decreased vision in patients older than 40 years. We do not see with our eyes. We see with part of our brain that is capable of interpreting visual signals sent back from the eyes. This is located at the back of our head (the occipital lobes).

Neuro-ophthalmology is an ophthalmic subspecialty that addresses the relationship between the eye and the brain, specifically disorders of the optic nerve, orbit, and brain, associated with visual symptoms. Neuro-ophthalmologists provide comprehensive clinical care to a broad spectrum of patients with visual disturbance from optic nerve diseases, central nervous system disorders, ocular motility dysfunction, and pupillary abnormalities.

This is the most common cause of sudden decreased vision in patients older than 40 years. We do not see with our eyes. We see with part of our brain that is capable of interpreting visual signals sent back from the eyes. This is located at the back of our head (the occipital lobes).

What are the common types of neuro-ophthalmic diseases?

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A few of the most common neuro-ophthalmic conditions are optic neuritis, ischemic optic neuropathy, compressive optic neuropathy (including pituitary tumors), papilledema, inflammatory and infectious optic neuropathies, cerebrovascular disorder involving vision, tumors involving vision, blephrospasm & hemifacial spasm, thyroid eye disease, myasthenia gravis, ocular motor disorders (including cranial nerve palsies), pupillary abnormalities, hereditary optic neuropathies and patients who have unexplained visual loss.

 

 

What are the common symptoms of neuro-ophthalmic diseases?

Symptoms that are more common in neuro-ophthalmic disease include visual loss, visual disturbance, diplopia, unequal pupils and eyelid and facial spasms.

 

What is papilledema?

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This is a condition in which high pressure inside your head can cause problems with vision and headache. In papilledema cerebrospinal fluid outflow is blocked. The pressure is transmitted to the back of the eye via the optic nerve sheath (surrounding each of the optic nerves) producing the swelling seen at the disc (papilledema).

 

 

 

 

 

How is the cause for papilledema detected?

The patient requires a MRI scan. The diagnosis also requires a spinal tap.. In rare cases, an angiogram, where a catheter is placed in the arteries and veins going to the head, may be necessary to exclude an abnormality of the blood vessels. To determine whether there is further damage to the optic nerve acuity and visual field testing is necessary.

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How will I know if I have papilledema?

The most common symptoms of high intracranial pressure are headache and visual loss. The headache may be located anywhere; frequently in the back of the neck. It is usually steady but may be pounding. It may be very severe, and unlike migraine, it may awaken the patient in the middle of the night. It also may worsen with bending or stooping. The optic nerve swelling may eventually lead to loss of vision seen as dimming, blurring or graying of vision. Patients may be aware of difficulty seeing to the side. Frequently patients notice visual disturbance lasting for a few seconds (often associated with bending or stooping). High pressure may cause damage to the nerves that move the eyes resulting in double vision. Patients may also be aware of a rushing noise in their ears. Nausea and vomiting may occur if the pressure is high and especially with a severe headache. Peripheral vision (detected on visual field testing) is usually abnormal and is one of the most important means of judging both the necessity for and effectiveness of treatment.

How is papilledema treated?

Reduction in CSF production or increase in its outflow may reduce intracranial pressure. Weight reduction programs (in overweight patients) may be effective. Continuous drainage may be surgically accomplished by placing a catheter between the spinal canal and the abdomen (lumbo-peritoneal shunt). In patients with worsening visual fields or decrease in central acuity, who do not have severe headaches, an optic nerve sheath fenestration may protect the optic nerve from further damage. A small hole or multiple slits are placed in the optic nerve sheath just behind the eye using an operating microscope.

How is a pituitary tumor detected?

Pituitary tumors are usually suspected based on endocrine changes but are confirmed with imaging studies. A CT scan can reveal a pituitary tumor and may be especially sensitive to hemorrhage. MRI scanning may be more sensitive and better define the relationship of the tumor to the optic nerves and surrounding structures. Blood studies to check pituitary function are essential.

How would I know if I have a Pituitary tumor?

Patients with pituitary tumors often have no symptoms at all. Occasionally these tumors may produce headaches. Head pain may be sudden and severe if there is a bleed into the tumor. Endocrine symptoms are most common including alterations in menstruation, lactation (milk from the breast), impotence, or loss of sex drive. Less commonly, tumors may produce growth hormone causing gigantism in young patients or enlargement of hands, feet, and facial features (acromegaly) in older patients. The most common of these symptoms is due to compression of the optic nerves or chiasm. Patients with involvement of one optic nerve may notice dim, dark, or blurred vision. If the chiasm is affected, vision will be lost off to the outside in both eyes.

 

8Do I have Multiple Sclerosis (MS)?  

Multiple sclerosis (MS) is a disease process where the body’s immune system attacks multiple areas in multiple episodes. An episode of optic neuritis may be the first indication of multiple sclerosis. With a single episode, without other evidence of involvement, we usually cannot make the diagnosis at that time. An MRI scan may be helpful in dividing those patients into high and low risks. Finding evidence of other areas of inflammation on MRI scanning suggests you may be at higher risk for recurrent episodes and thus MS.

 

 

 

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What is Optic Neuritis?

This is the most common cause of sudden visual loss in a young patient. It is often associated with discomfort in or around the eye, particularly with eye movement. The optic nerve fibers are coated with myelin to help them conduct the electrical signals back to your brain. In the most common form of optic neuritis, the optic nerve has been attacked by the body’s overactive immune systemA viral infection that may have occurred years, or even decades, earlier may have set the stage for an acute episode of optic neuritis. The inflammation associated with optic neuritis can result in discomfort (particularly with movement of the eye).

How is optic neuritis treated?

Patients treated with oral (pills) steroids seem to have a higher chance of recurrent episodes. Therefore, steroid pills alone are not recommended as treatment. Patients who were treated with intravenous (given by needle) steroids did have a slightly more rapid recovery of their vision, although the final visual outcome was not better than in those who were not treated. Thus, IV steroids can be recommended for patients with severe involvement or involvement of both eyes.

 

What is the outcome of nerve palsies?

There is no known means of accelerating the natural recovery characteristic of microvascular cranial nerve palsy. It is important to make sure that blood pressure and blood sugar are adequately controlled. The double vision may be treated acutely with patching either eye. It is very important that patients report any new symptoms or failure of the double vision to resolve.

What tests are done for nerve palsies?

All patients with presumed microvascular cranial nerve palsies should have their blood pressure and blood sugar checked to make sure they do not have diabetes or hypertension. Additional work up such as CT or MRI scans or even an angiogram to rule out an aneurysm may be necessary.

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Permanently lost. We do know that this happens more often in patients who are born with small optic discs. These episodes may occur when there is a sudden drop in blood pressure (following an operation or associated with blood loss after an accident). Patients who smoke, or who have diabetes or high blood pressure, may be at higher risk for AION.