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Neuro Study Cases. Optometry 8570 Winter 2008. Case History. 74 year old AA female presents to the Optometric Center on 3/31/05 for Eye Exam CC: Glasses broke and feels vision “blurrier” in left eye

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neuro study cases

Neuro Study Cases

Optometry 8570

Winter 2008

case history
Case History
  • 74 year old AA female presents to the Optometric Center on 3/31/05 for Eye Exam
  • CC:

Glasses broke and feels vision “blurrier” in left eye

  • Last exam 1year ago, was referred for cataract surgery. Surgery not done due to MD felt there would be no improvement in vision
march 31 2005
March 31, 2005
  • Review of Systems
  • (+) HTN - controlled by meds
  • (+) MI x 4, last one 2004
  • (+) Arthritis
  • (+) IDDM x 20+ years
  • Past/Present Ocular History
  • (+) IDDM x 20+ years, Previous focal laser OU

Focal laser OD - late 90’s

Focal laser OS - 2001

  • (+) Advanced cataracts OU
  • (+) 2001 “chicken pox in eye” - OS
march 31 20051
March 31, 2005
  • Current Medications
  • Amiodarone 200mg QD - Heart
  • Bisacodyl EC PRN - Constipation
  • Toprol XL 100mg QD - Hypertension
  • ASA 81 mg QD - Blood Thinner
  • Hydralazine HCL 25mg TID - Hypertension
  • Furosemide 20mg BID - Heart
  • Warfarin 2.5mg QHS - Blood Thinner
  • Aldactone 25mg QD - Diuretic
  • Lisinopril 40mg BID - Hypertension
  • Amitriptyline HCL 50mg QHS - Depression
  • Humulin 70/30 40units QHS - Diabetes
  • Humulin 70/30 10units QHS - Diabetes
march 31 20052
March 31, 2005
  • Unaided acuities

OD: CF@ 8ft - PH 20/200+ (PAP: 20/80)

OS: CF@ 5ft - PH 20/200+ (PAP: 20/120)

  • Left exotrope - noted in previous exams
  • Confrontations

OD: Full

OS: Full

  • EOMs

Full range on motion OU, but not smooth - poor fixation esp in superior gaze

  • Pupils

OD: P 5-3 RRL

OS: P 5.5-5 RRL

-OS pupil very slow/mild reaction to light, no APD

-Anisocoria is greater in the light vs dark

-Mild ptosis OS

march 31 2005 anterior segment

Mild ectropian

Mild inferior chemosis

Fuch’s dystrophy - central pigment

Grade 1 PSC

Grade 3 cortical cataract

Grade 3 nuclear cataract

IOP 19mmHg @11:32am


Mild ectropian

Mild inferior chemosis

Fuch’s dystrophy - central pigment > OD

Grade 1+ PSC

Grade 3 cortical cataract

Grade 3 nuclear cataract

IOP 21mmHg @11:32am

March 31, 2005Anterior Segment
march 31 2005 posterior segment difficult view secondary to significant cataracts ou

C/D: 0.2/0.2

Scattered dot hemes

Focal laser scar - nasal to fovea

Dot hemes in periphery


C/D: 0.3/0.3

Scattered dot hemes

Focal laser scar - inferior to fovea

Dot hemes in periphery

March 31, 2005Posterior Segment (Difficult view secondary to significant cataracts OU. )
march 31 20053
March 31, 2005


  • Longtime >20 years IDDM with retinopathy
  • Fuch’s corneal dystrophy OU
  • Significant nuclear and cortical cataracts OU, mild PSC, no improvement with PAP
  • Today pt presents with ptosis - not previously noted, but previously present????
  • Today pt presents with anisocoria - OS > OD. Difference greater in light vs dark. OS not fixed, but only SLIGHTLY reactive to light
  • No APD
  • Left Exotrope - noted previously
  • EOMs - full in all gazes, but pt did not always maintain fixation, especially in superior gazes
march 31 20054
March 31, 2005
  • Patient’s “helper” in HUGE hurry to leave, Call-A-Ride was waiting
  • No time to do any further tests
  • What are you thinking?
  • DDx?
what are the management options
What are the management options?
  • Do nothing - diagnose third nerve palsy secondary to diabetes and monitor patient?
  • Have patient back to rule out Adie’s tonic pupil?
  • Immediate referral for MRI/MRA to rule out aneurysm?


  • Pt long-time >20+year IDDM
  • Mild ptosis - is this new, or previously present and not noted?
  • Previously noted left exotrope in involved eye
  • Left pupil larger and only slightly reactive to bright light (from BIO)
clinical manifestation of a third nerve palsy
Clinical Manifestation of a Third Nerve Palsy
  • Patients may present with binocular diplopia, ptosis, anisocoria, or a combination of these
  • If related to subarachnoid hemorrhage, patients will have other neurological alterations:

-Alteration of consciousness

-Trouble cooperating with ocular motilities

-Eye on involved side is deviated “down and out”

-Prominent ptosis is usually present

  • Diabetic or Ischemic third nerve palsy typically spares the pupil
cranial nerve iii
Cranial Nerve III
  • Cranial Nerve III is divided into:

1. Superior division - supplies the SR, levator

2. Inferior division - divided into 3 branches supplying the MR, IR, IO

-The branch of the IO contains parasympathetic fibers of the oculomotor nerve that synapse in the ciliary gangion. The postganglionic fibers pass through the short ciliary nerve to supply the sphincter and ciliary muscles.

Pupil involvement resulting from posterior communicating artery aneurysm with or without an overt subarachnoid hemorrage
  • Pathophysiology of the third cranial nerve lesion involves leakage of blood from the aneurysm dome into the nerve across its outer margin. Pupil fibers are located superficially and are almost always involved
  • A pupil sparing third cranial nerve palsy is the hallmark of ischemic lesions that tend to involve the central core of the nerve - these often result from microvascular disease and tend to resolve in a few weeks
peripheral autonomic neuropathy in long standing diabetics
Peripheral Autonomic Neuropathy in Long-standing Diabetics
  • Patients with long-standing diabetes may present with slightly dilated, tonic pupils
  • The poorly reactive pupils are caused by diabetic autonomic neuropathy affecting the innervation of the pupillary sphincter. These patients usually have bilateral pupillary involvement
  • Conflicting reports state that tonic pupils secondary to diabetes will not caused segmental denervation as seen in Adie’s, while other reports state they can have a segmental palsy
  • Tonic pupils have also been reported secondary to PRP for diabetic retinopathy. This is thought to occur secondary to choroidal nerve damage from the laser
adie s tonic pupil
Adie’s Tonic Pupil
  • Patient presents with a dilated pupil and either a poor to absent reaction to light
  • There is slow constriction to prolonged near effort and slow redilation after near effort
  • Patients have a hypersensitivity to cholinergics - test to confirm Adie’s
    • Instill 0.125% Pilocarpine - Adie’s pupil should constrict, normal pupil will not…
    • If no constriction, instill 1% Pilocarpine
  • Etiology - Unknown in most cases
    • More common in females (70% vs 30%)
    • Young adults 20-40 yrs old
    • Segmental palsy of iris sphincter
    • Occurs in patients with deep tendon reflexes
patient management
Patient management….
  • To rule out Adies, called patient to return to Optometric Center on April 14th.
  • Will check pupils with 0.125% Pilocarpine. If no constriction, then will test with 1% Pilocarpine.
  • If still no constriction, should we refer????
april 14th
April 14th…
  • Pt called after appointment time to say that neither “helper” nor Call-A-Ride came
  • Pt rescheduled for Monday April 18th
  • Later found out that “helper” stole frame from the Optometric Center at March 31st appointment
april 18th
April 18th…
  • Patient was called to confirm appointment
  • Patient stated that Call-A-Ride called her to say that there were “people in greater need than her and were unable to pick her up”. Patients daughter got on the phone and confirmed this to Zan. Zan offered to call Call-A-Ride to explain situation and daughter refused to give number stating it would make things worse for her mother.
  • Later - patient’s other daughter called unaware of previous appointments. She stated that patient’s daughter (aka: “helper”) is on drugs and has chronically abused Call-A-Ride. Therefore, they are hesitant to pick up patient. Patient’s other daughter is to bring is patient on April 20th.
april 20th
April 20th…
  • Patient No-Showed appointment
  • No answer at patient’s home…..
aquired third nerve palsy
Aquired third nerve palsy
  • May be partial or complete
  • If intraocular muscles involved (pupil, ciliary body) - there is a fixed dilated pupil with paralysis of accommodation
  • Etiology - unknown, vascular (diabetes, HTN), aneurysm, head trauma, and neoplasm
  • Diabetic third nerve palsy rarely involves the pupil and usually recovers 100% of function
  • Clinician should rule out mucormycosis and other infectious Dz in any diabetic with any acquired oculomotor palsy- Why?
65 yo wm
65 yo WM
  • Presents with cc of blurred vision OD for uncertain duration
  • BVA: 20/30 OD, 20/20 OS
  • Fundus exam through clear media reveals confluent soft drusen OU
  • Pupils recorded as normal (examination performed by assistant)
  • Reduced VA attributed to soft drusen
  • Patient given Amsler grid and scheduled for 1 year appt
65 yo wm1
65 yo WM
  • Over the next 6 months, the patient’s vision gets worse and he consults your colleague in another practice
  • BVA is now 20/100 OD and 20/25 OS
  • APD now noted OD
  • HVF shows a temporal hemianopic defect OD
  • Imaging shows a a large tumor elevating the optic chiasm; most is extrasellar
65 yo wm2
65 yo WM
  • What is the most likely type of tumor to cause these findings?
  • Patient must undergo transcranial (rather than the safer transshenoidal) removal of lesion
  • Final BVA 20/50 OD, HM OS
  • Are you culpable? Why or why not?
15 yo hm
15 yo HM
  • Cc: 3 episodes of vertical diplopia lasting several hours each over the previous 2 months
  • The last episode was accompanied by “the feeling that I couldn’t walk straight for a while”
  • He feels fine in your office, and his eye exam is normal
  • You tell him to return if symptoms recur
15 yo hm1
15 yo HM
  • 6 months later, he experiences an explosive onset of diplopia, garbled speech, and 4-limb weakness
  • Your exam now shows bilateral horizontal gaze palsies, severe dysarthria, and quadraparesis
  • MRI of the brain now shows findings consistent with pontine AVM with acute hemorrhage
  • One year after the scan, the patient remains paralyzed
15 yo hm2
15 yo HM
  • What are the diagnostic pitfalls here?
  • Where did the clinician go wrong in the work-up?
  • What could have prevented this patient’s life-altering outcome?
case 4
Case # 4

70 y.o. W.F. with a medical Hx significant for HTN. She presents in the dispensary with c.o. double vision with her new glasses. You check the glasses and it is exact to your Rx and almost the same as her old glasses.

VA: 20/25 OD & OS.

Pupils: Normal

What questions do you ask?

What in-office procedures do you need to perform?

case 5
Case # 5

A 32 y.o. W.M. presents with double vision in almost all fields of gaze. He also c.o. a great deal of pain from his right eye that worsens with eye movement. You notice that the OD is also red.

VA: 20/25 OD, OS

Pupils: Normal

The EOM’s show some restriction in all F.O.G. but has the easiest time in the action of CN IV and can elevate both eyes in primary gaze and demonstrates no ptosis.

case 6
Case #6

A 27 y.o. W.F. presents to the office with complaints of progressive double vision. Her friends notice that on occasion her right eye turns inward at the exact moment she notices double vision.

VA: 20/20 OD & OS with RGP CL’s

Pupils: Normal

OD bulbar conjunctiva is red and the cornea shows significant staining but no complaints.