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Neuropthalmaology- Interactive Session

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					            Interactive Session
                 Neuro-ophthalmic Cases.

                                          September 2006.


                                Excerpts From
                     CME Neuro-ophthalmology.

                                                            1 / 19
September 2006          www.riogohchennai.ac.in
Case No. 1
    30 yrs male
    Complaints:
         sudden loss of vision in LE.
    O/E
         Neuro - cutaneous markers
          were found.




September 2006                 www.riogohchennai.ac.in   2
SLE Shows.




September 2006   www.riogohchennai.ac.in   3
Other Findings
    Pupils- RAPD.
    Fundus shows the following picture-.




September 2006           www.riogohchennai.ac.in   4
MRI Findings T1 And T2 Images




September 2006   www.riogohchennai.ac.in   5
MRI Findings T1 And T2 Images




September 2006   www.riogohchennai.ac.in   6
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 ?




September 2006            www.riogohchennai.ac.in   7
                 Answer To Case No. 01
1.      Diagnosis : type 1 neurofibromatosis with optic nerve
        Glioma.
2.      Markers: Lisch nodules, iris Mammilations, optic nerve Glioma,
        retinal Astrocytoma, various Meningiomas of brain.
3.      Two of seven criteria: café au lait spots, neurofibromas,
        Axillary freckles, Lisch nodules, optic nerve glioma, sphenoid wing
        dysplasia, positive family history.
4.      Management: periodic observation. Surgical management-
        when visual acuity is compromised.
5.      DD: optic nerve sheath Meningioma.

September 2006                  www.riogohchennai.ac.in                   8
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.


September 2006          www.riogohchennai.ac.in   9
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.



September 2006                  www.riogohchennai.ac.in   10
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?
September 2006       www.riogohchennai.ac.in      11
                 Answer To Case No. 02
1.      Diagnosis: right sided sixth nerve palsy.
2.      DD: Duanes syndrome type 1.
3.      Causes: DM, raised ICT, viral illness, others.
4.      Management: complete neurological work up and hematology.
5.      Duanes syndrome: is a restrictive squint caused by co-
        contraction of medial and lateral Recti.
6.      Other syndromes: Gradenigo syndrome; Godt- Fredson
        syndrome; Mobius syndrome; Raymonds syndrome; Fovilles
        syndrome.
7.      Role of surgical management: if diplopia persists beond six
        months.


September 2006                 www.riogohchennai.ac.in                12
Duanes Retraction Syndrome.




September 2006   www.riogohchennai.ac.in   13
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.

September 2006                    www.riogohchennai.ac.in   14
On Examination




September 2006   www.riogohchennai.ac.in   15
On Examination
    LE is divergent
    LE -EOM are restricted
     except abduction
    Pupil dilated
    Fundus normal
    Diplopia charting-
     crossed diplopia
    RE appears normal


September 2006          www.riogohchennai.ac.in   16
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 ?




September 2006        www.riogohchennai.ac.in      17
                 Answer To Case No. 03
1.      Diagnosis: complete left sided third nerve palsy.

2.      Approach: assess the level of lesion and compliment with
        complete neurological workup.


3.      Investigation of choice: MRI.

4.      Assessment of 4th nerve:
          Prompting to the patient to look down in abduction gaze – watch
             for intorsion.


September 2006                   www.riogohchennai.ac.in                    18
                    End of presentation.




September 2006           www.riogohchennai.ac.in   19

				
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