bitten by ophthalmology
DESCRIPTION
Bitten by Ophthalmology. Professor Helen Danesh-Meyer University of Auckland. 5 Keys steps for assessment of optic nerve function. VA Colour Vision Relative afferent pupillary defect Visual Field Optic Nerve. 1. Visual Acuity. Best Corrected. Pinhole. Papillo -macular bundle. - PowerPoint PPT PresentationTRANSCRIPT
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Bitten byBitten byOphthalmology Ophthalmology
Bitten byBitten byOphthalmology Ophthalmology
Professor Helen Danesh-Meyer
University of Auckland
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5 Keys steps for assessment 5 Keys steps for assessment of optic nerve functionof optic nerve function
5 Keys steps for assessment 5 Keys steps for assessment of optic nerve functionof optic nerve function
• VA
• Colour Vision
• Relative afferent
pupillary defect
• Visual Field
• Optic Nerve
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1. Visual Acuity1. Visual Acuity1. Visual Acuity1. Visual Acuity
Best Corrected
Pinhole
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Papillo-macular bundlePapillo-macular bundlePapillo-macular bundlePapillo-macular bundle
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GlaucomaGlaucomaGlaucomaGlaucoma
• A collective term for group of potentially blinding ocular conditions
• Characterised by peripheral visual field loss and characteristic changes to the optic nerve head
• Can be:– primary (occur by themselves), or – secondary (other ocular condition causes it)
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Primary Open Angle Primary Open Angle GlaucomaGlaucoma
Primary Open Angle Primary Open Angle GlaucomaGlaucoma
• Adult onset (> 40yrs)
• Angle normal and open
• Higher IOP greater risk
• Glaucomatous optic nerve head damage
• Visual Field loss
Normal
Glaucoma
cup disc
cup disc
c/d = 0.3
c/d = 0.8
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Open Angle GlaucomaOpen Angle GlaucomaOpen Angle GlaucomaOpen Angle Glaucoma
• Asymptomatic
• Genetic
• Visual loss is irreversible
• Most common cause of preventable blindness
• Treatment is lifelong
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2. Colour vision 2. Colour vision 2. Colour vision 2. Colour vision
• Optic nerve disease has decreased colour out of proportion to VA.
• Red desaturation classic for compressive optic neuropathies
• Tests:– Ishihara– Red target
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3. Relative Afferent Pupillary 3. Relative Afferent Pupillary DefectDefect
3. Relative Afferent Pupillary 3. Relative Afferent Pupillary DefectDefect
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3. Relative Afferent Pupillary 3. Relative Afferent Pupillary DefectDefect
3. Relative Afferent Pupillary 3. Relative Afferent Pupillary DefectDefect
• Objective sign of optic nerve compromise
• Can be used to monitor progression
• Provides a comparison of the two optic nerves
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Relative Afferent Pupillary Defect Relative Afferent Pupillary Defect (RAPD)(RAPD)
Relative Afferent Pupillary Defect Relative Afferent Pupillary Defect (RAPD)(RAPD)
• Test in dim room with pt looking at the distance
• Use bright source of light about 30cm from pt’s eyes
• Swing light b/w the eyes (2-3 sec on each eye)
• Make your decision within 2-3 swings
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ObserveObserveObserveObserve
Photopic illuminationScotopic illumination
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Light responsesLight responsesLight responsesLight responses
Consensual responseDirect response
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Light responsesLight responsesLight responsesLight responses
Direct responseConsensual response
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Abnormal responseAbnormal responseAbnormal responseAbnormal response
Right Relative AfferentPupillary Defect
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Circumstances when RAPD Circumstances when RAPD assessment difficultassessment difficult
Circumstances when RAPD Circumstances when RAPD assessment difficultassessment difficult
• Both pupils dilated
• Dark irides
• Elderly- small constricted pupils
• Damage to iris by surgery (cataract)
• Presybopic examiner
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Surrogate Tests for RAPDSurrogate Tests for RAPDSurrogate Tests for RAPDSurrogate Tests for RAPD
• Brightness sense
• Red perception
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Brightness senseBrightness senseBrightness senseBrightness sense
• Test in dim room with pt looking directly at the light
• Use bright source of light
• Ask:1. Is light equally bright in both eyes?2. If light is 100% bright in this eye (or worth
100 dollars) then how many percent (or how many dollars) is it in the other eye?
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4. Visual Field Assessment4. Visual Field Assessment4. Visual Field Assessment4. Visual Field Assessment
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Anatomy of visual pathwayAnatomy of visual pathwayAnatomy of visual pathwayAnatomy of visual pathway
Right eye Left eye
Temporal TemporalNasalNasal
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Anatomy of visual pathwayAnatomy of visual pathwayAnatomy of visual pathwayAnatomy of visual pathway
Modified from Kahle W.Frotscher M: Color Atlas and Textbook of Human Anatomy. 5th ed. Stuttgart: Thieme. Vol.3 p.355, 2003
Optic nerve
Nasal retina
Optic chiasm
Optic tract
Optic radiation
Temporal retina Temporal retina
Lateral geniculate body
Striate cortex
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Case 2Case 2Case 2Case 2
• 24 yr old male
• ~ 1 yr Hx of headaches, worse last 2-3/12• Examination: 6/6 OD 6/6 OS
No RAPD
Pallor + Pallor +
• CT head – pituitary adenoma
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Visual Fields – 2/7 pre-op
39 year old: 6/6 VA both eyes39 year old: 6/6 VA both eyes39 year old: 6/6 VA both eyes39 year old: 6/6 VA both eyes
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Visual Acuity
Pupil Testing
Visual Fields
Colour vision
Fundus Examination