Interactive Session Neuro-ophthalmic Cases. September 2006

1
Interactive Session

• Neuro-ophthalmic Cases.
• September 2006.
• Excerpts From
• CME Neuro-ophthalmology.

2
Case No. 1

• 30 yrs male
• Complaints
• sudden loss of vision in LE.
• O / E
• Neuro - cutaneous markers were found.

3
SLE Shows.
4
Other Findings

• Pupils- RAPD.
• Fundus shows the following picture-.

5
MRI Findings T1 And T2 Images
6
MRI Findings T1 And T2 Images
7
Discussion

• What is the diagnosis ?
• What are the ocular and neurological
  manifestations?
• What are the criteria to diagnose?
• How do you manage this case ?
• What is the DD ?

8
Answer To Case No. 01

• Diagnosis type 1 neurofibromatosis with optic
  nerve Glioma.
• Markers Lisch nodules, iris Mammilations, optic
  nerve Glioma, retinal Astrocytoma, various
  Meningiomas of brain.
• Two of seven criteria café au lait spots,
  neurofibromas, Axillary freckles, Lisch nodules,
  optic nerve glioma, sphenoid wing dysplasia,
  positive family history.
• Management periodic observation. Surgical
  management- when visual acuity is compromised.
• DD optic nerve sheath Meningioma.

9
Case No. 02

• 40 yrs woman with complaints of double vision for
  2 weeks.
• No history of trauma.
• No vasculopathic risk factors.
• No other neurological deficit.

10
On Examination

• Face turned to right.
• RE Esotropic.
• RE abduction restricted.
• Other EOM full.
• Diplopia charting shows uncrossed diplopia with
  maximum separation of eyes in dextroversion.
• Fundus - normal.

11
Discussion

• What is the diagnosis ?
• What are the DD?
• What are the common causes?
• How do you investigate?
• What is DUANES syndrome?
• What are the syndromes associated with 6th nerve
  palsy?
• What is the role of surgical management?

12
Answer To Case No. 02

• Diagnosis right sided sixth nerve palsy.
• DD Duanes syndrome type 1.
• Causes DM, raised ICT, viral illness, others.
• Management complete neurological work up and
  hematology.
• Duanes syndrome is a restrictive squint caused
  by co-contraction of medial and lateral Recti.
• Other syndromes Gradenigo syndrome Godt-
  Fredson syndrome Mobius syndrome Raymonds
  syndrome Fovilles syndrome.
• Role of surgical management if diplopia persists
  beond six months.

13
Duanes Retraction Syndrome.
14
Case No. 03

• 28 yrs female.
• Complaints of
• Drooping of left UL - sudden in onset.
• On LE lid elevation there is diplopia.
• No vasculopathic risk factors.
• No other neurological problems.

15
On Examination
16
On Examination

• LE is divergent
• LE -EOM are restricted except abduction
• Pupil dilated
• Fundus normal
• Diplopia charting-crossed diplopia
• RE appears normal

17
Discussion

• What is the diagnosis?
• How do you approach ?
• What is the investigation of choice?
• How do you assess 4th nerve function in the
  setting of complete 3rd nerve palsy ?

18
Answer To Case No. 03

• Diagnosis complete left sided third nerve palsy.
• Approach assess the level of lesion and
  compliment with complete neurological workup.
• Investigation of choice MRI.
• Assessment of 4th nerve
• Prompting to the patient to look down in
  abduction gaze watch for intorsion.

19

• End of presentation.