The Neuro-Ophthalmology The Neuro-Ophthalmology of Multiple Sclerosis of Multiple Sclerosis Charles Maxner MD, FRCPC Charles Maxner MD, FRCPC Professor, Departments of Medicine (Neurology) and Professor, Departments of Medicine (Neurology) and Ophthalmology Ophthalmology Dalhousie University Dalhousie University Consultant, Dalhousie MS Research Unit Consultant, Dalhousie MS Research Unit Halifax , N.S. Halifax , N.S.
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The Neuro-Ophthalmology of Multiple Sclerosis Charles Maxner MD, FRCPC Professor, Departments of Medicine (Neurology) and Ophthalmology Dalhousie University.
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The Neuro-Ophthalmology The Neuro-Ophthalmology of Multiple Sclerosisof Multiple Sclerosis
Charles Maxner MD, FRCPCCharles Maxner MD, FRCPCProfessor, Departments of Medicine (Neurology) and OphthalmologyProfessor, Departments of Medicine (Neurology) and Ophthalmology
Dalhousie UniversityDalhousie UniversityConsultant, Dalhousie MS Research Unit Consultant, Dalhousie MS Research Unit
Halifax , N.S.Halifax , N.S.
Dr. C.E. Maxner: DisclosureDr. C.E. Maxner: Disclosure
Dr. Maxner has attended and conductedDr. Maxner has attended and conductededucational events and participated in MSeducational events and participated in MSresearch studies affiliated with the followingresearch studies affiliated with the followingfirms:firms:
MS diagnosed 12 years priorMS diagnosed 12 years priorCopaxone TherapyCopaxone TherapyDecreased vision left eyeDecreased vision left eyeProgressed over 48 hoursProgressed over 48 hoursPain on eye movementPain on eye movementImpaired depth perceptionImpaired depth perception““Can’t drive”Can’t drive”
Case: Ms. H.B. 35 YOWFCase: Ms. H.B. 35 YOWF
ExaminationExaminationVa 6/6 Right, HM LeftVa 6/6 Right, HM Left
Central scotoma left eyeCentral scotoma left eye
RAPD 1.5 log units left eyeRAPD 1.5 log units left eye
Impaired colour perception leftImpaired colour perception left
Ocular motility normalOcular motility normal
Left disc slightly swollen and hyperemicLeft disc slightly swollen and hyperemic
Pupil Testing
QuickTime™ and aH.263 decompressor
are needed to see this picture.
Case: Ms. H.B. 35 YOWFCase: Ms. H.B. 35 YOWF
Goldmann Visual FieldsGoldmann Visual Fields
Case: Ms. H.B. 35 YOWFCase: Ms. H.B. 35 YOWF
Va 6/6 Right, 6/9 LeftVa 6/6 Right, 6/9 Left
Central blur left eyeCentral blur left eye
RAPD 0.6 left eyeRAPD 0.6 left eye
Colour improvedColour improved
Temporal pallor left discTemporal pallor left disc
Follow Up: 3 months laterFollow Up: 3 months later
Uhthoff described 3 patients in whom Uhthoff described 3 patients in whom exertion and fatigue caused a desaturation exertion and fatigue caused a desaturation in colour visionin colour vision
Patient XVIII had decreased acuity after Patient XVIII had decreased acuity after walking around the roomwalking around the room
What did he describe?
Who was Uhthoff?
Uhthoff’s SymptomUhthoff’s Symptom
Wilhelm Uhthoff (1853-1927)Wilhelm Uhthoff (1853-1927)Born Warin , GermanyBorn Warin , GermanyStudied in Tübingen, Göttingen, BerlinStudied in Tübingen, Göttingen, BerlinConsultant at Westphal’s Clinic (With Oppenheim, Consultant at Westphal’s Clinic (With Oppenheim,
Wallenberg, Thomsen, Möbius)Wallenberg, Thomsen, Möbius)Named Professor of Ophthalmology at Breslau 1896Named Professor of Ophthalmology at Breslau 1896Eye Symptoms in Diseases of the Nervous System Eye Symptoms in Diseases of the Nervous System
(Published 1915)(Published 1915)Described by Bielschowsky as the “true originator” Described by Bielschowsky as the “true originator”
of clinical neuro-ophthalmologyof clinical neuro-ophthalmology
Wilhelm UhthoffWilhelm Uhthoff
Uhthoff’s SymptomUhthoff’s Symptom
Uhthoff’s symptom in optic Uhthoff’s symptom in optic neuritis:relationship to MRI and neuritis:relationship to MRI and development of MS.development of MS. (Scholl GB, Song HS, (Scholl GB, Song HS, Wray SH) Ann Neurol 1991; 30(2):180-4Wray SH) Ann Neurol 1991; 30(2):180-4
Uhthoff and his Symptom Uhthoff and his Symptom (Selhorst JB, (Selhorst JB, Saul RF) Journal of Neuro-ophthalmology Saul RF) Journal of Neuro-ophthalmology 1995; 15(2):63-91995; 15(2):63-9
FlashesFlashes
Movement phosphenes in optic Movement phosphenes in optic neuritis: A new clinical signneuritis: A new clinical sign (Davis F, (Davis F, Bergen D, Schauf C, McDonald I, Deutsch W) Bergen D, Schauf C, McDonald I, Deutsch W) Neurology 1976; 26: 1100-1104.Neurology 1976; 26: 1100-1104.
Bright flashes in darkBright flashes in dark
Eye movementEye movement
Differentiate from Lightning Streaks of MooreDifferentiate from Lightning Streaks of Moore
Eye equivalent of Lhermittes symptomEye equivalent of Lhermittes symptom
Hx: Hx: • 2 week history of “dizzy” feeling and 2 week history of “dizzy” feeling and
disorientation with looking downdisorientation with looking down• Difficulty focussing on rapid EOM’sDifficulty focussing on rapid EOM’s• 2003 sensory symptoms in legs and Lhermittes 2003 sensory symptoms in legs and Lhermittes
Most accurate method for identification of INO is Most accurate method for identification of INO is quantitative EOM recordingquantitative EOM recording
Clinical detection accuracy vs RecordingClinical detection accuracy vs Recording93% severe INO93% severe INO75% moderate INO75% moderate INO29% mild INO29% mild INOFrohman et al. Neurology 2003;61:848-850Frohman et al. Neurology 2003;61:848-850
Head Thrust TestHead Thrust TestHalmagyi ManeuverHalmagyi Maneuver
Thrust head 20-30 degrees while fixating targetThrust head 20-30 degrees while fixating target
Abnormal:Abnormal:
Refixation saccadeRefixation saccade
Headshake TestHeadshake Test
Shake head for 20 seconds at 2 hz (horizontal Shake head for 20 seconds at 2 hz (horizontal and vertical) with eyes closed, then open and vertical) with eyes closed, then open and observe for nystagmus (Frenzel lenses)and observe for nystagmus (Frenzel lenses)
Abnormal:Abnormal:Unidirectional nystagmus in plane of Unidirectional nystagmus in plane of headshake (peripheral)headshake (peripheral)Vertical nystagmus after horizontal Vertical nystagmus after horizontal headshake (central)headshake (central)
Fixate own thumb while chair rotatesFixate own thumb while chair rotates
Abnormal:Abnormal:
Nystagmus in direction of rotationNystagmus in direction of rotation
* VOR suppression test
Failure of VOR SuppressionFailure of VOR Suppression
QuickTime™ and aCinepak decompressor
are needed to see this picture.
Ophthalmoscopic TestingOphthalmoscopic Testing
Spontaneous nystagmusSpontaneous nystagmusRetinal slip: Observe fundus while patient fixates Retinal slip: Observe fundus while patient fixates
target and oscillates head at frequency greater than target and oscillates head at frequency greater than 1 cps1 cps
Abnormal: If the VOR gain is too high the disc Abnormal: If the VOR gain is too high the disc appears to move with the head , if too low, appears to move with the head , if too low, opposite the headopposite the head