Learn Connect Succeed. JCAHPO Regional Meetings 2017

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1 Learn Connect Succeed JCAHPO Regional Meetings 2017

2 NO FINANCIAL DISCLOSURES Technician s Role in Neuro-Ophthalmology Workup Beth Koch COT, ROUB Cleveland 9/16/2017 What Tests Are You Expected To Perform? What Role Do You Play? Good History Visual Acuity Refractions Retinoscopy Visual Fields (Humphrey / Goldmann) Color Vision Pupils Work-up EOM s CVF s Exophthalmometry Topography Schirmer s tear test Ultrasound (30 degree test) Other Imaging Where does your work-up start? History taking (complaints, POH, PHx, Social hx, FHx) Visual Acuity (BCVA, threshold, DV, NV, eccentric vs central) (Tests for difficult patients OKN drum, finger touch test, finger flick) Refracting (Nystagmus) Pupils 1

3 How does a neuro-ophthalmology Workup differ from general work-up The work up in neurophthalmology will depend on the patient you are seeing Just like in general ophthalmology but you may have more special testing to perform RAPD Checking Muscles (EOM) Checking Muscles (EOM) What nerves innervate these muscles? SO4 LR6 (MR, IR, SR, IO)3 Checking Versions and Ductions- It is important to check to see if both of these actions are equal in your patient -Examples of inequality may be seen in a child with an alternating ET or XT -Patient with Thyroid eye disease (EOM stiffness -Muscles entrapment in an eye injury 2

4 Left Eye Under active Right Eye Over-active Example (- 1) Example (+1) Example (-2) Example (+2) Example (-3) Example (+3) Example (-4) Example (+4) Types of patients you might see In neuro-ophthalmology Chronic headache patients - Pseudotumor - Papilledema - Giant cell arteritis - Migraines Chronic Headaches Pseudotumor / Papilledema -Can often have severe headaches -Pulsatile tinnutis (pulsing ringing /rushing sound in ears) -Diplopia -Transient vision loss -Visual field loss Chronic Headaches PseudoTumor Risk Factors: Obesity - Obesity has been associated with pseudotumor cerebri, which occurs in 1 to 2 people in 100,000. In women who are obese, about 4 to 21 in 100,000 develop the condition. Women under the age of 44 who are obese are more likely to develop the disorder. 3

5 Chronic Headaches Pseudo Tumor Risk Factors Medications Tetracycline Growth Hormone Excess vitamin A Giant Cell Arteritis / Temporal Arteritis -Generally effect women over the age of 50 -Symptoms include headaches, pain/tenderness in temporal region -Diplopia and vision loss -Dizziness and loss of coordination -Pain with jaw claudication -Scalp parathesia 4

6 Migraines -With or without headaches -With or without auras -Lonstanding history -Triggers Disorders of Intracranial Pathway -Stroke: Sudden loss of specific brain function F.A.S.T. = Face droop Arm weakness Speech difficulty Time to call 911 STROKE Visual field loss Paralysis/Paresis Aphasia -to what degree -how to check vision -communication Disorders of Intracranial Pathway Tumors Pituitary Early shows bitemporal loss Meningioma Arises from meninges Unique VF loss depending on location Can affect one or both eyes Can occur on same side both eyes or different Multiple Sclerosis What to ask: Onset of symptoms (systemic /ocular) Date of diagnosis Treatment 5

7 Multiple Sclerosis Patients with Multiple Sclerosis may suffer from Internuclear Ophthalmoplegia Making it difficult to check EOM s Internuclear Ophthalmoplegia This is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. When an attempt is made to gaze contralaterally (relative to the affected eye), the affected eye adducts minimally, if at all. The contralateral eye abducts, however with nystagmus. Thyroid Eye Disease Exposure keratopathy (lid retraction) Diplopia (d/t swelling/compression of EOM s) Visual Field loss (compressive optic neuropathy) Case 1 >50 year old patient Presents with double vision Sometimes vertical and sometimes diagonal Complains of lid drooping *You may have to perform Exophthalmometry on theses patients. What is the role you play in helping this patient? What subjective observations could you make to help your Doctor Body position as patient sits Is there a head tilt Good history Accurate visual acuity EOM s Pupil assessment Visual field testing 6

8 What might you ask to assist your physician Case 2 >40 year old female patient Presents with intractable headaches Obesity History of headaches Auras or scintillations Diplopia (transient) Vision loss (transient or decrease) Tinnitis Oscillopsia What tests could you perform? Visual fields Optic nerve photos 30 degree test (ultrasound) 7

9 30 Degree test (positive is more than 10% change) Pseudotumor Cerebri PTC Definition MRI/ MRV: Normal LP: Opening pressure 25 cm or more Normal CSF composition Neurologic Exam Normal : Except 6 th nerve palsy No structural or systemic causes for increased ICP Case 3 Female patient in her 30 s 40 s Presents with sub-acute vision loss Notes peripheral and central vision changes What questions might you ask Pain prior to vision loss History of prior episodes History of headaches History of MS What Tests Could You Perform Visual acuity Color Vision Visual field testing OCT Optic Nerve Optic disc photos 8

10 Optic Neuritis Subacute vison loss usually associated with pain Visual acuity: 20/25 to No Light Perception Variable visual field defects websites Dyschromatopsia often impaired more than visual acuity 9

11 Photo Credits 30 degree test by Brandy Lorek, ROUB CDOS from Ophthalmic Ultrasound by Arun D. Singh MD & Brandy C. Hayden (Elsevier) Map of visual pathway (permissions from Thieme publishing) 10