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Home , Diplopia, Fourth nerve palsy, Hypertropia, Nystagmus, Optic neuritis, Sixth nerve palsy

6/5/2014

Common visual symptoms and findings in MS: Clues and Identification

Teresa C Frohman, PA-C, MSCS Neuro- Research Manager, UT Southwestern Medical Center at Dallas Professor Biomedical Engineering, University of Texas Dallas

COMMON COMPLAINTS

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Blurry Vision

Corrected with ?

YES NO

Refractive Keep Looking Error

IN MS : ON, ,

Most Common Visual Issues Encountered in MS patients

• Optic • Diplopia • Nystagmus

result from damage to the optic or from an incoordination in the eye muscles or damage to a part of the oculomotor pathway or apparatus

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Optic Neuritis Workup

‘frosted glass’ Part of missing +/- Color desaturation Work up for Yes diplopia or nystagmus Seeing double images YES NO Or ‘jiggling’ No

Neuro-ophth exam Humphrey’s OCT MRI Fundoscopy

CRANIAL NERVE ANATOMY

 There are 12 pairs of cranial  CN I Smell  CN II Vision  CN III, IV, VI Oculomotor  CN V Trigeminal Sensorimotor muscles of the Jaw  CN VII Sensorimotor of the face  CN VIII //vestibular  CN IX, X, XII Mouth, esophagus, oropharynx  CN XI Cervical Spine and shoulder

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NEURO-OPHTHALMOLOGY EXAM

 Color Vision  Afferent pupillary reaction- objective test of CNII function  Alternating flashlight test – afferent arc of pupillary light reflex pathway  Fundus exam  Visual Fields –confrontation at bedside

CRANIAL NERVE II: OPTIC once the retinal ganglion cell leave the back of the eye they become myelinated behind the lamina cribosa ---and become the

Optic nerves pass through the optic canals and converge at the optic chiasm They continue to the where they synapse From there, the optic radiation fibers run to the Functions solely by carrying afferent impulses for vision

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CRANIAL NERVE II- OPTIC NERVE

Assessment Cranial nerve II  Snellen Chart  Visual Acuity – snellen chart  Patient’s own /contacts  Visual Fields – confrontation  Pinhole  Fundoscopy  Pupillary light reflex  Pinhole refraction is a rapid, efficient way to diagnose refractive errors, which are the most common cause of . However, with pinhole refraction, best correction is usually to only about 20/30, not 20/20.

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CRANIAL NERVE II- OPTIC NERVE

 Assessment Cranial nerve II Test by confrontation Assess superior, temporal, inferior and nasal  Visual Acuity – Snellen chart fields  Visual Fields  Fundoscopy  Pupillary light reflex Humphrey’s Automated Perimetry

 Damage to an optic nerve results in blindness in the eye serviced by that nerve

 Damage to visual pathways distal to the optic chiasm results in partial visual losses.

 Visual defects are called anopsias.

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VISUAL FIELD DEFECTS Location of lesion: 1. Optic nerve

Visual fields ipsilateral (same side) blind eye

2. Chiasmatic (pituitary tumors classically) 1 lateral half of both eyes gone

3 2 1. 3. opposite half of visual field gone 3. 2. 4. & 5. Distal to geniculate ganglion of thalamus: 4 homonymous superior field (4) or 5 homonymous inferior field (5) defect

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CRANIAL NERVE II- OPTIC NERVE

 Assessment Cranial nerve II  Visual Acuity – snellen chart  Visual Fields  Fundoscopy  Neuro-retinal rim-axons of RGC  Orange pink w/central cup  Axons die--white=pallor  Pupillary light reflex

Normal pallor

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CRANIAL NERVE II- OPTIC NERVE

 Assessment Cranial nerve II PUPILLARY LIGHT REFLEX  Visual Acuity – snellen chart Direct light reflex  Visual Fields  Fundoscopy Consensual light reflex  Pupillary light reflex Swinging flashlight test APD, afferent pupillary defect

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LEFT RELATIVE AFFERENT PUPILLARY DEFECT Normal Left /Neuropathy

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OPTIC NEURITIS WORKUP

 Typically vision returns within a few weeks to months

 Many affect color vision even if acuity returns to 20/20

 Can cause a large ‘blind spot’ in center of visual field

 OCT will show thinner RNFL-

 OCT on the Cirrus OCT evaluating peripapillary RNFL thickness shows decreased average thickness, with thinning predominantly of the temporal aspects of both optic nerve heads.  MRI -fat suppressed T1 weighted post gadolinium images.

Optic Neuritis Workup

‘frosted glass’ Part of visual field missing Pain +/- Color desaturation Work up for Yes diplopia or nystagmus Seeing double images YES NO Or ‘jiggling’ No

Humphrey’s OCT MRI Fundoscopy

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QUESTION TO START WITH

Is it Unilateral or Bilateral  Diplopia- caused by two images  No double vision with monocular viewing = or problem

DIPLOPIA

 Diplopia (double vision), the experience of seeing two of everything, is caused by weakening or incoordination of eye muscles or supranuclear leasion (skew deviation)

 Common causes of Diplopia in MS  INO  6th Nerve Palsy > 3rd nerve palsy > 4th nerve palsy  Skew deviation

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EYE MOVEMENTS

Controlled by CN III, IV, & VI CN III  superior rectus  inferior rectus  medial rectus  inferior oblique CN IV  superior oblique CN VI  lateral rectus

Superior = “in crowd” = intorters Inferior = “out crowd”= extorters

DIPLOPIA

Internuclear Ophthalmoplegia  Common causes of Diplopia in MS INO •adduction slowing with or without limitaton  INO •Most common oculomotor abn in MS  6th > 3rd > 4th Nerve Palsy •Lesion of MLF –ipsilateral •Can cause diplopia when making  Skew deviation away from side of lesion

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CN III, OCULOMOTOR

 Innervates SR, IR, MR, IO  Elevates , levator palpebrae  Constricts via sphincter muscles of  Contraction of ciliary muscle reduces tension on lens allowing focusing on closer objects  A common treatment for this is to place an eye patch on the stronger (dominant) eye in order to strengthen the weaker muscles of the affected eye.

CRANIAL NERVE IV: TROCHLEAR

 Fibers emerge from the dorsal midbrain and enter the orbits via the superior orbital fissures; innervate the  Primarily a motor nerve that directs the eyeball

Fourth Nerve Palsy Double vision following palsy is most prominent when the patient adducts their eye, such as when walking downstairs or reading a book. Patients may also hold their head in a tilited position to compensate.

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CRANIAL NERVE VI: ABDUCENS   Sixth nerve palsy results in a patient unable to abduct the eye. It is also a false localizing sign in raised or basal skull fracture. The long course of the leaves it vulnerable to pressure changes.

 In abducens nerve paralysis, the eye cannot. be moved laterally; at rest, the affected eyeball turns medially (internal ), giving a person a 'cross-eyed' condition.

IS IT HORIZONTAL OR VERTICAL

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4TH NERVE VS SKEW DEVIATION

 4TH NERVE PALSY  SKEW DEVIATION   1. in primary position 1. Hypertropia in primary position   2. Incomitant: hypertropia worse on gaze to 2. Incomitant, comitant, or alternating opposite side acutely; may become comitant with time  3. Hypertropia may or may not change with head tilt  3. Hypertropia worse on ipsilateral head tilt  4. Pathologic head tilt contralateral to the  4. Compensatory head tilt contralateral to the hypertropic eye hypertropic eye  5. Incyclotorsion of the hypertropic eye if present  5. Excyclotorsion of the hypertropic eye (and excyclotorsion of the hypotropic eye)  6. Usually no other neurologic signs (unless  6. Usually has other neurologic signs (eg, gaze-evoked caused by trauma or lesions in brainstem) nystagmus, gaze palsy, , , hemiplegia)

Optic Neuritis Workup

‘frosted glass’ Part of visual field missing Pain +/- Color desaturation Work up for Yes diplopia or nystagmus Seeing double images YES NO Or ‘jiggling’ No

Humphrey’s OCT MRI Fundoscopy

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NYSTAGMUS  Nystagmus: Upon examination, the physician may detect a rhythmic jerkiness or bounce in one or both eyes. This relatively common visual finding in MS is nystagmus. Nystagmus does not always cause symptoms of which the person is aware. Mononcular Occluded fundoscopy

 Sometimes nystagmus can accompany INO, but it can also be due to any type of MS attack in the vestibular or inner ear part of the brainstem, or to the , which is our coordination center.

Final Thoughts

 In summary, vision can be impaired by MS in many different ways.  People with MS who experience visual problems may benefit from an evaluation by both a neurologist and an ophthalmologist, or a neuro-ophthalmologist if one is available.  Uhthoff’s Phenomenon- esp: ON and INO

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THANK YOU

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