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Welcome to SNI Digital Innovations in Learning in association with UCLA Neurosurgery. Linda Liao, chairwoman and its faculty are pleased to bring you the UCLA Department of Neurosurgery 101
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lecture series on neurosurgery and clinical and basic neuroscience.
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This series of lectures are provided free to bring the advances in clinical and basic neuroscience to physicians and patients everywhere. One out of every five people in the world suffer from a
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neurologically related disease. The lecture and discussion is on neuro ophthalmology, orbital and neuro ophthalmic examination pearls for the neurosurgeon. The lecturer is Justin Carlin, UCLA
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Health Sciences Assistant Professor of Ophthalmology, Division of Orbital and Ophthalmic Plastic Surgery, Ronald Reagan, UCLA Medical Center, Los Angeles, California, United States of America So
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I'm Justin Carlin, I'm in the department of oculoplastic surgery, but I sort of dabble sometimes in the neuro-ophthalmology, I have an interest in it. I don't see a lot of those patients
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necessarily, but I find it really interesting. So I hope this will be relevant to you, especially for the residents and the trainees, because the truth of the matter is, when you have a busy
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night on a call, you have to gather accurate and useful information, okay? That's the key. You don't have a lot of time. from all different directions. So you have to be able to identify what it
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is you're seeing and then how you can use that information to make a decision without it actually being inaccurate and therefore dangerous. Okay, so I'm gonna try to help sharpen your observation
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skills a little bit and then I'll present some, hopefully some clinical radiological correlations for you. And that's what's gonna be, I think in your career, especially if you end up alone in
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Wyoming, you don't have access to like high level neurothermology Hopefully this can help you with your surgical planning, narrow your differential, assess the patient's functioning ahead of time,
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you know, on your own, so you can see it with your own eyes. And also for medical legal reasons before you embark on an operation, it's a good idea to have documented what the patient's vision
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might be, what the patient's motility, these sorts of things. And so I'll show you how to gather that information, okay? And when you do operate afterwards, I know it's very important to assess
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your own outcome and vision being such an important and motility, such an important part of people's function. Understanding how to assess the vision is going to be important in assessing your
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post-operative evaluation and then rehab, okay?
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So, I'll paraphrase what Harvey Cushing said. He said the ophthalmologists, which were the first surgical subspecialties neurosurgeons, which are the latest, sort of meat at the border of the
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optic for Emmon. And we're kind of, we look at each other, kind of a little bit of a scance at what our roles are, but we know that we're both working on the same thing. So, this is the
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structure of the talk I'll go through so I can make it kind of clear to you some of the, this is how I structure the way that I do an exam as well when I see patients. So, we'll start with the
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afferent system, which afferent just means vision. What's a patient's vision? How do they see? What do they seem? If you have the opportunity to take a history in a patient with a visual
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complaint, you want to know, is there a change? Is it one eye or both? Where in the visual field? A lot of times patients can't even express it. But if you can get that information, it's useful
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for the bottom part, which is neurologic localization, where's the actual problem so that you can then determine what to do next? So, you know, and a patient can have anything from cataract to
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optic atrophy to a cholesterol aneurysmal bone cyst to a occipital tumor that can cause vision loss.
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Harry Traquair, the Scottish ophthalmologist, described the way we see, and I think the best, the best understanding that I have is that most of our sensitivities in that central 10 degrees,
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called an island or a hill of vision, okay? And that corresponds to most 90 of the axons that are in your optic nerve, function to serve the macula, the very center of the vision, and your brain
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kind of fills in the rest, okay? So there's the macula, which is that center about 10, 15 degrees of your vision, and then there's extramacular, which is the visual field. So this is how the
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computer works, okay? This is how the software works, okay?
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So when you examine someone's eye, do one eye at a time. if you can, if you can actually get that information from the one eye at a time. And the way you can do that in the clinic, the way we do
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it is I give patients a near card or I have them look at the Snell-in chart, I can check their color vision. But if you're at the bedside and you don't have a lot of time, I'll show you some ways
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to do it. But basically you can give them a target and see if they can follow it with each eye. Okay, it's called fix and follow. Okay, cover one eye, move a target around, see if they can
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follow it around. Another thing that I think really gives you kind of a global assessment is if the patient can give you information, look at my nose, okay? How much of my face can you see? And
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you can do one eye at a time, cover one eye with your palm, cover you? How much of my face can you see? That gives you an idea of what's going on about the central 10, 15 degrees of vision. Now,
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can you see my eyes, can you see my nose? And again, you're just trying to gather information as quickly as possible. So I have a few of these kind of quizzes around, especially for the residents.
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For those of you who've seen my slides already now for four years, like forgive me because it's a lot of the same examples. But does anybody know what I'm trying to get at here,
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So that's when you get a some arachnoid hemorrhage and a actually that that tracks forward to the macula and patients can have significant loss of vision at the level of the retina, because of this
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sort of boat shaped sub high alloyed hemorrhage. And that can actually end up quite scarred and they can lose vision permanently for that so it's this is important to assess
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So we talked about macular function which is sort of that center 10 15 degrees for outside the macula it's going to be the visual fields again one eye at a time when you're in the clinic you have all
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kinds of tools. Okay, we have, you can a common neural one they use in neurology the acid patient to draw something, and that gives a lot of information as to what they actually perceive okay,
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but at the bedside it's not so, it's not so easy so Or with children for that matter so what you can do again one eye at a time, you can ask a patient to imitate if you're going to ask them to to
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count the fingers you should only use. one, two, or five. One, two, or five. Because it's really hard to tell the difference between three and four. Or even one, and two, and then two, and
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five, and one, and five. So one, two, or five, and then you cover one eye, and then you can do it in the perfect. We'll practice on each other, okay? Obviously, blink to threat. You can
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ask a patient to, you know, cover one eye, and then say, okay, do you see this?
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And then if they look, it gives you some information, okay? So when you do check vision, it's important to check both of those systems, the center as well as the periphery, okay?
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Why send a patient for formal visual fields? Obviously, this is for early detection of lesions and what the functional ramifications would be. And this used to be the only way for anatomic
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localization and it still has value today because sometimes what something looks like on a scan is not necessarily correlated to what it actually does to a patient's vision So something might be
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growing on an MRI, but it may not necessarily have an impact. on what you would expect with the visual center. So it's important to assess that it can narrow your differential diagnosis. It can
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help you monitor the patient's progression, as I mentioned, and also it can sometimes reveal hidden vision loss that you didn't expect based on what you know about the patient's imaging. So Harvey
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Cushing, who's definitely one of my heroes, he really understood the star power. You know, today, a lot of people are trying to do their Instagram, and he got that 100 years ago. So he was in
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Time Magazine, he had articles written about it. He made sure that whenever he was photographed, that he always looked really good. If you go online onto YouTube, he actually filmed his 2000th
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operation. I don't know if you've seen this, it's incredible. It's about a half an hour long video about his 2000th confirmed brain tumor, and they show the whole surgery. I mean, it's like
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Babcock by Babcock, it really is amazing. So if you have a chance, just go to YouTube. and look up Harvey Cushing's 2000th operation. But he said, by temporal visual defects, visual field
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effects are the signature of chiasmal disease, and it's so true. And he worked closely with an ophthalmologist, multiple ophthalmologists to painstakingly describe the variation in visual field
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defects with a variety of lesions, with particular
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attention paid to chiasmal disease.
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This was an arc perimeter that was used by Clifford Walker.
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I won't go through the history this time, but you can look through it later in the slides. But one thing that was interesting was Wollaston, who was one of the first ones to really report about
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crossing of fibers of the chiasm, actually himself had a brain tumor, and went up there and said, this has been my experience with what it's like to have a
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bi-temporal
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Okay, so anatomy quiz.
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We're looking at the, at the cella and, and the client, anterior clinoids, but you see those question marks. Can somebody tell me what those structures are there? It's what, where the, where
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the tie has them kind of sits. What's that called?
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Limbus. Limbus, right. Exactly. And so limbus is the, is the word for, anterior and posterior limbus. And limbus is the word for border. Like limbo, limbus. Okay, limbo
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When you talk about the relationship of the chiasm to the cella, we generally describe it in three different orientations. Okay, the chiasm's always anterior to
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the infinibulum, but in relation to where the gland is, the chiasm can be
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in front of the gland in the cella, over the gland in the cella, or it can be posterior to the gland in the cella. It just depends on the sort of the intracranial length of the optic nerve. Okay
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Here's, I think this is an even better diagram. looking from above, I suppose, showing there on the bottom where the orientation of the chiasm is in relation to the cella, okay?
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So we know that from below, from above, you can have various lesions that can impinge on the chiasm. You can even have intra-axial chiasmal disease.
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Everybody's seen this diagram. Not every patient reads the textbook, but generally you can reason out based on what you see on the imaging and what you know in this diagram to correlate what the
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patient has on psychophysical testing with what's on the imaging. So here's an example of a patient, let's say with a post-fixed chiasm, where the chiasm is posterior to the cella and posterior to
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the gland, meaning that you have a longer intracranial optic nerve segment. And let's say that there's a lesion coming from below. that's pressing on just one optic nerve, you may expect that you
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would have a defect in only perhaps one portion of the optic nerve, one portion of the visual field of one eye. This is the so-called troquair scotoma, which is sort of a temporal hemianopia in one
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eye, okay? Troquair scotoma. Then if you move, oh, wait a second. Let me see if I can, you know what I'm gonna do. I'm just gonna share my whole screen. I don't feel like I'm using my
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presenter notes
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Because I have quizzes for you.
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Good. So this is the so-called junctional scotoma. So the last one we saw, again, post-fix chiasm, affecting one of the nerves would cause something like this. If it's the nerve and part of the
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chiasm, it really might take out one visual field completely, and then also part of the other one. This is called the junctional scotoma. And then I have another quiz for you. If anybody can tell
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me what this
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leisure might be
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Yeah,
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that's right, Tuberculum and angioma.
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OK, so when the chiasm is oriented, just superior to the gland and the cella, you would expect a bi-temporal. And the bi-temporal can be partial, can be superior, can be inferior, it can be the
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whole thing. And dense,
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if it's a pre-fixed chiasm, meaning a short intracranial length of the optic nerve, meaning the chiasm is oriented anterior to the cella, it means any lesion that's coming from above or below onto
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the chiasm might then imping on the tracts. And if it impinges on the tract, you would expect it would cause more of a,
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homonymous.
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Okay, this is the case I saw in residency. He had presented to an outside ophthalmologist endorsing vision loss on one side and the ophthalmologist had ordered an MRI. And while he was waiting, he
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showed up to the emergency room with acute vision loss. And the worst vision you can have as ophthalmologists describe the very bottom is NLP, no light perception. And oftentimes that's like pretty
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much the point of no return. Once you have NLP, it's like, you can't really come back from that, okay? NLP. So this is pituitary apoplexy.
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And in this case, it affected one optic nerve preferentially and the other one was normal. little cartoon visual field there.
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One common, if you go and look at Harvey Cushing's records, when he took pictures of patients, I think this is so cool. He almost very often showed the hands. So when he would take pictures in
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his records because he felt like the hands gave a lot of information. So you may notice, and then these descriptions of the patients, it's just, it really is fascinating. This to me was pretty
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good This is another case of apple plexi. This patient came in with what looks like an adenoma, absence of secondary sexual characteristics with complete vision loss in one eye in a very small
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island in the other eye.
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And hematoma evacuated, did better and then passed away shortly thereafter. And then you have not only the clinical photo, you've got the radiology, the visual field, the autopsy and the
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histopath I mean, and this was meticulous records for every patient. I think it contributed so much the understanding of medicine in general that meticulous record keeping is such an important habit
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to develop.
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Okay. This is a 72-year-old man with a bi-temporal heminopia. Can anybody tell me what this one is?
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based on the histopathology.
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Joe, cranial, cranial, right. So there are two types of cranial for angioma. Okay. Do you know the two types?
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Ademantinomatus, right? And the way you can tell that is I think the ademantinomatus has calcifications which are those purple things.
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Okay, I have a lot more notes in here. So when you look at my slides, if you ever get a chance, there's a lot of information There's a lot of information here for you, but I don't want to dwell
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on it too much because we don't have a lot of time.
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Okay, this is a, demonstrates a
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glioblastoma of the occipital lobe
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causing a inferior right quadrantanopia
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I'm on a mess
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I'm honest means it's the same in both eyes, okay?
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So this is a 23-year-old woman who, and this is a case you might see, okay, this is a case you might see in real life, who was noted by the optometrist to have bilateral
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optic disc swelling, and in large blind spot, and on imaging had low-lying cerebellar tonsils and an empty cella, and she had this phenomenon called, when she had
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transient blurry vision when she stands up or bends over, which is any cause of swelling of the optic nerve, whether it's due to increase intracranial pressure or due to something intrinsic to the
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nerve, will, it may cause this phenomenon of the symptom of transient blurry vision when they stand up, okay,
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which is called TVO or transient visual obscurations So this is IIH, a patient. who will start with an enlarged blind spot that moves progressively as the
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pressure on the nerve remains for longer periods of time into a constricted visual field. It's very rare for somebody with IIH or actually elevated intracranial pressure in general to lose vision
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completely. Almost always, it comes down to a very constricted field But they almost never lose vision completely. It's one of the few conditions. Glaucoma's like that too. And so elevated
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intracranial pressure in glaucoma are like cousins. Intracranial, elevated intracranial pressure is glaucoma of the brain. And then glaucoma is glaucoma of the eye. And they both have this same
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kind of visual field pattern where patients often go down to a very, like looking through a straw, okay? But focal neurologic deficits in patients with IIH is uncommon And this is like I said,
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this is called TV or transient visual obscurations, okay?
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It's sort of like orthostatic hypotension of the nerves. So when they stand up or they change positions, they kind of, the vision goes out and comes back. Okay, gray out, brown out, black out,
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something like that.
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The eye. Oh yeah,
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that's what I said. Okay, and we'll talk a little more about the neural imaging of elevated ICP later on.
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So, and we'll talk a little bit about pseudo-pseudo-tumor. Okay, pseudo-tumor is another term for IIH, but you always have to watch out for pseudo-pseudo-tumor, which is looks like IIH, looks
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like elevated intracranial pressure, but it's actually just weird optic nerves. Okay, we'll talk a bit about that later. So that kind of covers some of the afferent system. Okay, I think we're
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pretty much on time.
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Then we'll delve a bit into the ocular motor system, which has many different ways. different, little software packages that go into controlling how the eye moves, okay? There's the sort of the
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movement range, which is important, there's how the eyes are aligned when you fixate on a target, either centrally or eccentrically, there's, and then we're not going to talk about sort of gaze
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holding, nastagmus, kind of smooth pursuit versus saccades
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But I just want to talk about kind of the big things about how to assess eye movement.
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If a patient has a double vision, there are a few key questions
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that you have to ask. First of all, does it go away when you cover one eye?
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And then if they can tell you, what's the orientation of the two images in relation to each other? If they can tell you, I brought a prism and some, so we can play around with kind of what it
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looks like to have double vision just so you can kind of get an idea, and in case you're curious And if they can answer that question, the orientation, then you can ask, well, which, when you
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look in a certain direction, is it worse? and you can kind of turn their head and assess that. Not always possible, but if you can. And here's a, based on the binocularity versus monoculars,
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binoculars suggest something intracranial, typically infertentorial,
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diplopia that's monoculars something in the eye, okay? Rarely it's something in the brain, very rarely it can happen. Monocular diplopia or triplopia can happen very rarely due to certain
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conditions in the brain, but very, very rare.
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I think this diagram is great because it shows the three axes along which the eye rotates, okay? And then there are muscles to do all of those things. In general, the degrees of movement are
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listed here. So when it comes to looking in the horizontal direction, it's about 50 degrees. And I'll show you what that looks like. So it's about 50 degrees horizontally And then looking down,
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it's about 45. looking up actually, your ability to look up decreases with age, okay? That's that sort of age, dependent loss of upgase, just so you can get some idea.
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When you're in the clinic, we have a million different ways to look at motility. We've got you can put two filters on the eyes with lights. You can, there's these things called HESS screens and so
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forth. But if you're at the bedside, I'm going to give you some tricks to be able to assess what the alignment is and maybe even see more subtle changes if you need to. Okay. And there's something
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called the HERSHBERG test. Okay. The HERSHBERG test is where you shine a light into the both patient size and then you look at where the light reflexes in relation to
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the pupil or the limbus. And this can give you some general idea of what the positioning of the eyes. And we can practice on each other just so you can get some idea. If the. that light reflex,
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so the reflection off of the cornea is at about the limbus, what we call our limbus, which is the border of the iris and the sclera, that's about 45 degrees, okay? So you can shine a light and
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ask the patient to look and then you can see if the light reflex is oriented at the same place. It's not quantitative, but it can give you some idea, okay? It's called the Hirschberg test. We can
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practice that So here's a case study of a patient with a complete ptosis and then when you lift up the eye, it looks like unopposed action of the superior oblique and lateral rectus. And you can't
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really see the pupils here, but if you could, you might assume that this is a third nerve pulse, complete third nerve palsy. And this patient has a posterior communicating aneurysm. There's this
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Twitter account called, her name is Leah Ali-Hali. She's a neuroadiologist She makes these really, for people like me who don't see aneurysms a lot. want to learn about. I think it's really nice
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the way that she describes, so it's a cartoon about what the risk is of rupture. And if you want to, I can send you her. It's really cool. So she kind of talks about it in a way that I can
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understand. But obviously, the most common reason for cranial nerve three, one of the more common reasons for cranial nerve three palsy is a posterior communicating artery aneurysm. And there are
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obviously multiple different types, usually at the junction of the posterior communicating in the carotid. Here's an example of a third nerve palsy in a left third nerve palsy partial in a child
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with us aqueductal stenosis. That was from Harvey Cushing's case log. So here's the course of the third nerve and just about everywhere along the pathway, it's possible to have a lesion and there
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are the various segments. So
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when the third nerve exits the midbrain, it exits into the intrapeduncular fossa, And then there's the, there's a so-calledsisternal segment which is an intro - particular cistern or perimazins of
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Pollock's cistern. And then there are sort of two segments there before it gets into the
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oculomotor triangle here, which is ortoporus, which is this. It's between, and one, correct me if I'm wrong, but it's between the,
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yeah, I'll read it from your anterior, petroclinofold, the interclinoidal fold and the posterior petroclinoidal fold is where it enters into the dura and then into the cavernous sinus.
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And if you were to peel open that the porous, you can see that it's lined by arachnoid, okay? And that's a so-called trigonal segment as it enters into the triangle. Then, and here you can see,
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especially on the right of the screen, the intimate relationship between the
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cranial nerve three and the posterior communicating artery before it enters into the dura So again, here you can see the. the relationship between the cranial nerve three and the posterior
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communicating artery, even before it enters into the dora, into the porous, into that oculomotor triangle, beneath the anterior petroclinoidal fold. Here's sort of peeling away some of the dora,
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and then again, showing all those different segments along the way. So there's sort of this portion of cranial nerve three that's sort of exposed in the perimescence phallic cistern and that makes
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it liable to be compressed or stretched or damaged. Okay, we'll see that later on also, but that's sort of one of the vulnerable points to compression of cranial nerve three. And obviously as it
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enters into the orbital apex, it splits into the superior and inferior. The inferior has the pupillary fibers. And usually, but earlier on, the pupillary fiber is actually around the periphery of
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the nerve the delivery fibers are per free. that middle of the nerve is are the motor fibers. Okay, so the parasympathetic are on the outside. Okay, here's another case study of a patient of a
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man who comes in with diplopia, both eyes for getting worse over maybe the course of a year, and he states that his diplopia is able to articulate that his diplopia is worse looking right and down.
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So I've shown on the top
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right of the screen, in each direction of gaze, there's sort of a maximal action of a given muscle, and so if you see a defect in a certain gaze, you can presume that that muscle is affected.
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Okay, so I'll direct your attention to the to the bottom left of the screen, where you can see that the left eye is not going down enough, not as much as the right, okay?
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And on, it's worse on head tilt, to the left side, but it gets better with the right head tool. Does anybody have any idea what this could be?
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That's right. Very good. Which side?
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Left side. So left, left superior oblique is most activated on depression and a deduction. Okay, depression, a deduction is a superior oblique muscle. Here,
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the patient ended up having
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a. A I will have to look at my notes, but he has it tumor in the pineal region. Sorry, a tumor in the pineal region that's that's hitting the sort of the dorsal part of the ponds and midbrain.
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And that's, as you'll see, that's where the, that's what that's what makes cranial nerve for unique is that it exits dorsally.
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Kind of moving around into the perimesence of Alex cistern. And then here's a. This is a paper which had very specific MRI technique that was able to see the fourth nerve as it kind of was
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traversing through the various cisterns, ambient cistern, and toward the, around the peduncle toward the, it had its own pore into the dura as well, sort of long, skinny course, and then meets
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up in the cavernous sinus with the third nerve, because it starts off a little bit below to the third nerve is, but it has to get up to the superior oblique. So it has a bit of a, it has that long
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course, and then it kind of moves superiorly as it traverses forward. And of course it gets the superior oblique outside of the muscle ring. So the muscle ring or the annulus of zinn is there in
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red. And the fourth nerve is one of the nerves that's outside of the muscle ring because it's getting to that superior oblique. Here's another example of fourth nerve palsy, a couple of features
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here that I didn't mention when patients look.
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to a way from the side of the lesion. So if they look contralaterally, if you look at that leftmost image, you can see that the eye as the patient looks, the eye tends to go up like this, sort of
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like this. Nasal upshoot with adduction. So it's a hypertropeia. And the hypertrophy is also worsens on head tilt toward the side of the lesion, okay? It doesn't give you a ton of information to
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tell the difference between with what's called a skew deviation, which always confuses me, but these are the, this is the general idea with fourth nerve palsy. If you see a nasal upshoot and
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worsening on Ipsilato hotel, it's suspicious at least for a fourth nerve palsy. And again, you can see how you may be able to use the Hirschberg test. So it looked in the middle image, you can
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see that those two dots on the patient's right eye are right in the center of the pupil, the patient's left eye, they're sort of toward the bottom of the pupil. Now, provided the pupils are about
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equal size, you can use that to give some idea of what the deviation might be. Does that make sense? So that's the Hirschberg test. It's a qualitative test. Okay, so this patient with a
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pinealoma, literary attraction,
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upgaze palsy. The diagnosis is Parinod syndrome or dorsal midbrain syndrome, which is sort of more typical. I know the case I showed you is not a typical cause of a fourth nerve palsy. And then
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the other features that you should know are convergence, retraction, estagmus, and pupillary, light, near dissociation. Okay. So
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this is a 50 year old man with acute deplopia, which is worse on right gaze. And if you look at the patient, the image on the left, you can see when the patient tries to look to the right, the
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left eye does not
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adduct. Does that adduct? Does not go in? And so this is pretty typical for an internuclear of thaumalplegia and the patient has the hemorrhage in
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the midbrain at the medial longitudinal fasciculus. And here's a picture of it, here's a video of it. So you can see when the patient looks to
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the right, the patient's right. So this way, that looks pretty much normal, a little bit of engaged in the stagmus. Now you can watch that, that right eye has sort of a lag, see how it's kind
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of lags behind. So that's sort of more subtle internuclear of thromp Lags behind, and then there's also on the left eye, there's nystagmus, you see that? So those are the two features, okay?
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Adduction lag, and then more prominent nystagmus on
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the more normal eye, see that?
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And the reason why I think that this is important is there's a long list of differential diagnoses, and some of which are operative neurosurgical problems So you should familiarize yourself with this
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finding. Okay,
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here's another one 51 year old man double vision has plus coming out of the left ear and pain behind the left eye and a headache with this finding.
33:14
Anybody I know this is the same slides I show I've been showing for the last four years so if somebody who hasn't seen it does anybody know what this is called.
33:24
Did this tell us a lot? No, no. Good guess.
33:29
Gratinego. Nice. OK. So Gratinego, it's -
33:36
oh, he gave you the wrong answer. And then he took the credit.
33:40
That's treacherous.
33:43
That's treacherous. We don't see this that often, but this is a 6-nerve palsy plus retroorbital pain and mastoid or Petrus Apecitis,
33:54
or Petrus Apecitis
33:57
Here's another example of that, this is a patient with
34:03
who has double vision for about four weeks, some mild disk edema and a fourth nerve, excuse me, a sixth nerve palsy, which means an ABduction deficit, okay, this is sort of a zebra type case,
34:19
does anybody know this one? Okay, good. All right, cool Yeah, let me do Clo, which is, evidently, it's not Neoplastic, but it's this lesion that grows and the cells look,
34:32
cells look, there's an increased cellular layer and then there's these increased vacuoles and there's more blood vessels than you would expect.
34:42
So that's the, the pathway of the abducens nerve is, it sort of goes down and then it It does exit from the pawns at the bottom of the pawns. it does exit
34:59
much lower. And then it kind of travels along the cleivus up toward the cavernous sinus. And it's not altogether clear to me why, I know we talk about this every time, like why elevated
35:12
intracranial pressure causes six nerve palsy. And I think just as a general, it's fixed in certain places. And then if you have some measure of herniation, central herniation, I guess it's either
35:22
a stretching or it pushes on there And then it's fixed at where it enters into, so it exits the midbrain or the pons into the cistern. And then it goes up and enters the dura a bit more superiorly.
35:36
And
35:37
it must be fixed there as it enters the dorello canal under the glubertal ligament. And so perhaps that causes some stretching along that canal. I'm not totally sure, but we know that we see
35:48
occasionally increased or with increased intracranial pressure, we see six nerve palsy That's probably the more common one to see. go coming out of the Dorello canal and into the cavernous sinus
36:00
there.
36:02
So good, good, I think I'm clear for that. So the pupil, one thing to know about the pupil is it's rich with information. There's a lot of information that you can get from the pupil objectively
36:16
that
36:18
when a patient comes in and we suspect that, and they're complaining of vision loss, but we suspect that they're lying, the truth always comes out from the pupil, okay? The pupil is sort of, it
36:29
gives you a ton of information. If you know how to examine and understand the pupil, you can get a lot of objective, useful information from that, okay? I've showed a lot of different pathologies
36:39
here. There's a third nerve palsy up on the top. There's another type of third nerve palsy, which is sort of more omniskind. Here's Horner syndrome here on the very right of the screen. There's a
36:50
congenital Horner syndrome,
36:54
With the congenital horn or syndrome, you can see that the eyes are oftentimes two different colors. And then various different types of pupils. And then the one in the center, it shows the
37:04
patient having a light shining in one eye and it doesn't really respond. But then when they look at something up close, it does respond. That's called light near dissociation, okay? So the pupil
37:13
can give you a ton of information. And I'll show you how to examine the pupil, but the key things that you wanna look at is how big is it, how reactive is it, how equal are the two? And then if
37:23
you're feeling enterprising, you can try to look for an afferent pupillary defect, but really it's size, reactivity, and equality. If you can learn how to really observe well those things,
37:34
they're these little tools, you can get a pupilometer. I know now these days in the ICU, they're using these pupilometers for all kinds of monitoring of intracranial pressure. I don't know if the
37:42
ramifications are fully understood yet, but I think that that's going to become more and more useful.
37:53
Marcus gun pupil is an afferent pupillary defect, 80s tonic pupil is a condition that causes a type of partial third nerve policy, just affecting the pupil. So, afferent pupillary defect means
38:08
that we'll see it in a second means I think I have this video here. Yeah, here, this is an afferent pupillary defect. Okay, so that's also known as a Marcus gun pupil So you shine light in one
38:18
eye, constricts, you go to the other one, it dilates means that this patient's right eye is not seeing it's not receiving as much light as the left eye. Okay, this sort of the consensual response
38:28
right 80s tonic pupil means that the fibers that are control constriction, which is a parasympathetic fibers of three for whatever reason or damage maybe viral or whatever
38:44
Efarin problem. Efarin problem. This is a fair problem. That's exactly right.
38:50
So here's the pupillary light reflects. arc, here's a case of a patient who has, if you look closely, you can see on the patient's right near that letter A, that the pupil is a little bit smaller,
39:04
and that the lid is a little bit lower. Then if you ask the patient to look to the right, they also have a sixth nerve palsy. And this is one of those few times in ophthalmology where it really
39:15
gives you exquisite localizing information If you see a sixth nerve palsy with the Horner syndrome, it's cavernous sinus. It can't be anywhere else, okay? One of those sort of neural ophthalmic
39:26
pearls. It's the only time when the two of them are together, okay? Rare, but you put it in the back of your mind somewhere and then maybe you'll see it someday, okay?
39:37
There you go.
39:39
And obviously we're not gonna go through the whole pathway of the sympathetic as they travel up the aisle, three neurons and so forth. It's quite esoteric
39:47
Okay a is this, 29-year-old man struck on one side of the head. you see something like this, it makes you really sad because we know that the prognosis of a fixed dilated pupil unilateral or
39:57
bilateral in the setting of head trauma is a very poor prognostic factor.
40:03
So this is a coo-contrap, coo injury with subdural hematoma and then herniation of the onchus. I don't presume to try to talk to any of you about herniation or brain trauma or anything like that.
40:16
This was really mostly for my own understanding But what is not totally clear to me, but which I imagine is when the
40:24
onchus moves over the tentorial notch, there's a portion, that portion of the cranial nerve three is what's most exposed. And either it's compression or stretching or both. That's the way I
40:35
imagine it. Maybe correct me if I'm wrong. But as the
40:40
brain expands and the onchus comes over that tentorial notch, that portion of cranial nerve three is what's most affected and it can affect the.
40:51
it affects the parasympathetic first because those travel on the outside of the nerve. There's also a rare phenomenon, which if, let's say you're in the trauma bay and you see an oval-shaped pupil,
41:02
this could be a sign of impending herniation or impending problem because it's the so-called dynamic oval pupil, where initial pressure on that pupil can cause an oval shape or movement in a certain
41:15
axis. Now, it's not the only cause of an oval-shaped pupil, obviously, but in the setting of a trauma where you have anisochoria. And that could be a sign that there's an emergency about to
41:24
happen, OK?
41:28
All right. So we can blast through these last part in about 5, 10 minutes. This is the part that's sort of close to my heart, which is orbit and oculoplastics. It's pretty straightforward to
41:39
measure. A lot of it is photographic. A lot of it is observation. When we talk about how to measure the position of the eyelid, we use this metric called the margin reflex distance, OK? Again,
41:50
that corneal light reflects the distance to where the eyelid margin is. That's the margin reflex distance one, as you can see on the top. That's sort of our metric that we use to measure the
41:59
position of the upper eyelid. Hertel exophthalamometry or nogal exophthalamometry, we use to tell
42:05
the axial position of the globe. And obviously facial sensation, we both know how to test. So in the eyelid, we look at margin reflex distance. I also look at how far the eyelid moves from down
42:15
gaze to up gaze. And then I asked the patient to close their eyes gently I always say this, close your eyes like you're sleeping. 'Cause if you ask them to close your eyes, sometimes they do this
42:23
and you can't see the subtle. And so close your eyes like you're sleeping. And then you can see if they have lagophthalmos. So it was the patient of mine. He'd been complaining of left eye
42:31
irritation. And I noticed he had some trouble closing that eye. And so I sent him for a scan. And it's nice to get these kind of thank you notes every now and again, okay?
42:45
So this is an example of mechanical ptosis This patient has an encephalo-seal. probably pushing on the levator muscle with the defect in the superior part of the orbit on that left side.
42:55
Here's how you look at globe position, which is this hotel. I have a paper that I wrote on skull base, ophthalmology for the skull base, pathology and examination. And I describe in detail if
43:07
you're curious, you can look that one up. Here's what it looks like to have axial displacement, for example, in the case of a sphenoid wingman in Geoma. And the worm's eye view is the easiest way
43:18
to see that. Which means we're underneath. This is one, again, from Cushing's case logs. This is a patient with an optic nerve glioma, and you can appreciate it on the right side, both an axial
43:28
proptosis, as well as an exotropia, an
43:32
exotropia. Okay, it's hard to tell what the light reflects, but you can see that the eyes are kind of pointed out. It's because the right eye isn't seeing very well. Here's an example of both
43:40
axial, meaning the eyes pushed forward and non-axial. The eyes pushed down in the case of a mucus seal, and that's relieved once the reconstruction of the orbital roof and evacuation. Let's see if
43:53
we can play this.
43:57
So, orbital roof defect in some cases can cause this phenomenon which is the so-called pulsatile propitosis where you have the normal pulsations of the brain and the dura which is harder and more
44:11
firm than the orbital tissue are transmitted to the orbital tissues.
44:19
Facial sensation, just a couple of case reports, this patient came in with a binocular double vision as well as sort of a dull pain in the right eye and loss of vision on the right side was noted to
44:31
have recurrent nasopharyngeal carcinoma in the cavernous sinus. And for this level of damage and destruction to the cornea, the patient usually should feel something because the cornea has the
44:41
highest pain sensation in the body, highest pain sensation in the body So the patient should be feeling and the fact that they only feel a dull pain is indicative that there's a serious problem.
44:53
All right. When you do off filmoscopy. Yeah. Go ahead
45:10
Yeah, that's
45:14
a highly sensitive issue. Unlikely. Unlikely. Yeah. Usually the problem. Um, it's a good, I think, I think that's a really good question. I think that's really the first of all, first of all,
45:25
when I was a resident, we did a study where we looked at patients in the ICU and patients post stop. And a lot of them have unrecognized cornea and eye problems, unrecognized. It was about 30. We
45:34
found, okay. Um, we just troll the list and went through and then checked patients to see if they had problems and use the most common problem. It's not abrasion necessarily or mechanical damage
45:47
It's exposure is that the eyes not closing all the way, it's pretty unlikely that somebody's going to rub their eye, especially in that setting and actually cause damage. But what's much, much
45:56
more common is that the eyes not totally closed during surgery. And then it dries out. Okay.
46:03
So if you want to do off thou mask to be right, we will practice it together. Again, I brought a few, you hold it in your right hands. You look through your right eye at the patient's right eye.
46:12
And that way your nose doesn't hit theirs. You have to get pretty close And if you can, I mean, it seems like basic stuff, but if you don't remember these. things and you're not going to be able
46:19
to do it right. And then you can't get their useful information from it. But then if you practice it, you can get good at it. And it's something that you could just gather information quickly. I
46:27
remember I used to get called for, you know, by neurosurgery when I was a resident to come rule out papilladema. You know, there'd be this crying four year old who wanted to go home. And then if
46:39
you're able to do it right, and you can actually look in there and send the kid home, and then, you know, they're good. They don't have papilladema. So if you can get good with something like
46:46
this, if you have the time, you know, if you have the time, if you can get good with something like this, maybe you can gather some useful information once in a while.
46:55
I think so. I think so. You can darken it for maybe a couple minutes. If you have a time in the clinic, darken it for a few minutes, that'll dilate the pupil a little bit. Also have the patient
47:03
fixate it at a distance that dilates the pupil a little bit, okay?
47:08
We know that Harvey Cushing understood the value of off filmoscopy. And he actually knew that he could see patients with this diagnosis because he saw the vessels, but it's very hard to see out to
47:19
the periphery with direct off thalmoscopy.
47:30
Anyone?
47:32
Anyone?
47:34
Is Von Hippolyndale, cerebellar hmangeoblastoma, as well as retinal hmangeoblastoma? Okay,
47:43
here's another one where you have a one side that has disc atrophy and one side that has disc edema due to
47:51
tumor that's pressing on one nerve causing atrophy, but also causing elevated intracranial pressure, which is causing edema on the opposite nerve. You don't get a edema on an atrophic nerve, by
47:59
the way. Once the tissue's gone, it doesn't swell anymore. Okay, so what's this condition called? Foster Kennedy. Good. Okay, here's another one, a patient with
48:10
after trauma, head trauma, the patient has these tortuous vessels, even after adding phenylephrine or like basically like visine to the eye, they still have these curlicue vessels on the
48:22
conjunctiva. And then you look in the back, you see, on one side, on the same side, that is those curly Q-congeentime levels, you see this.
48:31
swollen
48:33
retinal veins, okay, swollen and tortuous retinal veins, which is indicative of
48:46
Okay, this is my final sort of public service announcement before we can start practicing a little bit. When you use a term papilladema, it means bilateral optic nerve swelling due to elevated
48:58
intracranial pressure. That's the term papilladema. When you use that, that's what it means. Both eyes have a disc that's swollen because the intracranial pressure is high.
49:09
Discadema is sort of even broader If you look at a Venn diagram, there's discadema, which is all of them, and papilladema is a smaller circle inside of it.
49:17
And pseudopapilladema, oh, by the way, on MRI findings for actual papilladema, you see some flattening or contour change of the posterior globe, and you see some T2 signal around the optic nerve.
49:33
That's sort of the couple of telltale signs on MRI on
49:38
CT, if you see something like this, this is not papodema. calcified dreusin, which can look a lot like papilladeum. And I'll tell you, I saw a patient who had calcified dreusin, who was sent
49:50
and actually had a shunt put in for many years and had low pressure headache for a while until somebody figured out that she had calcified dreusin, took the shunt out and she got better. So it can
49:59
happen, you know, you can make a error of judgment in doing a procedure if you don't have the right information, okay? So this is optic nerve head dreusin that you can see on CT So MRI is good for
50:12
actual pakoladema. CT is good for calcified dreusin. And if you have a suspicion about calcified dreusin and you're not sure, you can send to the ophthalmologist and they have these tests that they
50:22
can look for the buried dreusin, which are these deposits under the disc.
50:31
Okay. I think that pretty much covers it. I think I finished pretty much on time. Good. Any questions about what you - yeah, go ahead. It is a really great lecture. Thank you
50:43
for -
50:47
thank you for - thank you for coming. On the topic of Tucson syndrome, should we be - I mean, I guess, what's the instance that I've imagined that that varies with the Fisher grade of the
50:53
hemorrhage? But I wasn't aware that it scarves down. I was one of the assumption that it kind of goes away when it's the hemorrhage resolved, so this all suggests that we should be like, you know,
51:03
really doing off-project exams and high grade Fisher patients and then calling you if there's any ambiguity to that. I don't think that's unreasonable at all. I do. I guess, like, should do you
51:14
think that something? I mean, in a high grade, Subarachnoid hemorrhage patient, obviously a bigger fish to fry, you know. But if, for some reason, once the sort of just to settle, they don't
51:28
have vasospasm or whatever, you make sure that they're stable, it wouldn't be a bad idea to get an eye exam at some point because there's not really much you can do about it from an eye standpoint.
51:36
So it's not like, there really isn't. It's not like you can go drain the hemorrhage necessarily. So I don't think it necessarily makes logistical sense, but it would be a good idea as sort of part
51:49
of the rehabilitation plan to make sure that that's figured out and addressed
51:56
that the patient understands the ramifications, why that's happening. We talked about, sometimes when they're off the period of shoot, that is what they're saying. How sensitive are specific
52:02
patterns with the hemorrhage?
52:09
I think it's a good question. I don't think that that's, at least from my understanding, a very reliable measure. I know the emergency room likes to use it, and I'm sure we'll have more
52:19
information, but I guess the one liner is that it's pretty operator dependent.
52:26
does it all the time, and then you have some kind of correlation. Then maybe you could trust those results, but it's not something that I have a lot of, as a diagnostic test that I have a ton of
52:34
familiarity with, and might be center-specific or operator-specific. So, yeah.
52:41
Great talk, Justin. Can you speak on object nourishing penetration for pseudotumor, and what the barriers are for ophthalmology or after classes doing it, if it's worth doing versus just going
52:54
straight chance, if it's like just a visual problem or not, like spear head aches, et cetera. Absolutely. I mean, you hit the nail on the head. If patient has headache, shown to probably the
53:04
best neurosurgical, the best option overall, and that will address the neck.
53:11
But if they just have eye findings without a problem and a headache, then obviously doing this nerve sheet penetration is not gonna help with headache, but it can help with the eye findings. And
53:21
it's something that's pretty straightforward for our fellows that are sitting back there So it depends on what the most pressing issue is for that particular patient. There are patients who have
53:33
shown still have vision loss that we end up doing demonstrations on, which is possible. But that's really the main, as far as I understand it, the main separator, if headache is a big part of it,
53:43
you do a shunt, you can try to address everything. But if it's really mostly vision loss, minimal headache, then an optic nerve sheets of administration is the move And with that, you'd have to
53:55
stabilize the number of months so that they can try to lose weight and things like that. Right. It can at least keep the nerve stable while they get on diomox and lose weight.
54:09
So it's kind of a throw up on that. I think what Blond's getting at is that
54:12
they just - they aren't done here. But
54:15
we just call in the wrong service. So is it - should we call oculopastics rather than - I said call myself the doctor of the biology, because we just - you ask, and they're - Always rejected 80.
54:28
You like doing them, right?
54:31
Jesus. Oh, yeah
54:36
If somebody like Connie's doing it maybe 15 minutes Is
54:41
it is would you say that it's a I mean is it a Technically demanding or dangerous surgery? Is it hard to do I think you just need practice, but it's not like you have to spend a lot of time opening
54:54
or closing It's pretty straightforward to access the nerve, but it does take some technical understanding not to damage the nerve when you do something like that So we do it under the microscope. We
55:04
actually use the inner ear instruments Oftentimes and just take off a little window the Dura or the octagoner she
55:12
What is the approach? There are a couple different ways you can do it you can you can go through the medial upper eyelid crease Okay, you can go through the caruncle, which is that you know kind of
55:23
that fleshy part of the conjunctiva there immediately And some people will actually take the medial rectus off temporarily and then put the eye into abduction. So it makes the nerve available.
55:35
Others can just, you can just find it another way. I have to admit, I've done probably half a dozen of them. And I've noticed that for the fellows, for some people it comes really naturally. And
55:46
for some people it's just really, for me it's always been kind of tough to do. So I usually just let fellows do it, but yeah.
55:56
For the IH slide you were saying that they get transient blurry vision with bending over and standing up. But in terms of ICP, those are kind of like opposite things. Like usually ICP falls and
56:07
they stand. So why would. I'm not totally sure with postural change. It's a good question. I haven't talked to enough patients to really fully understand what that's like. But I know that it can
56:19
be when they, when you have an increase in ICP or a decrease in perfusion. So it's sort of like - That's the sort of way I think about it. If I be straining, there's obesity patients are trying to
56:30
get up from us in a position. No, Salva. Yeah, that could be true. I've heard that racism and the reason of God was to judge bilateral on the people of the fact that you overcoat such a.
56:42
Muscle and fat, those two things. So we separate them into like different types of disease. One type is with sort of much larger muscles And sorry, and the other one is with expansion of fat.
56:57
Usually if it's compression of the nerve and you have greater oxophthalimose when it's mostly a muscle disease, but you can have a lot of bulging with fat as well. But it's typically some measure of
57:07
both. And always bilateral. Not always. The most common cause of bilateral proptosis is thyroid eye disease. The most common cause of unilateral proptosis is thyroid eye disease. Proptosis due to
57:19
thyroid eye disease is more common than proptosis due to any other cause combined.
57:25
Okay, so thyroidizing is like the most common orbital disease by far.
57:32
Yeah, I want to echo, it's a great talk.
57:35
One of the things that we love working with your group and the mystery to me is
57:43
why you so seldomly reconstruct the orbital roof. Can you show a pretty nice slide of pulsatile, I guess I used to call it, Excel found what you call apoptosis, but every time we ask, Oh, no,
57:56
you'll need to. I mean, it's just so rare that you actually do, when do you need to reconstruct it? How much of the orbital
58:05
surroundings have to be missing before you get it? 'Cause I have to be a CSF leak. I mean, what is it? That's a mystery to me of what's - There's a lot of potential danger and anxiety coming out.
58:16
Yeah. It's like, yeah. Question answer session.
58:21
So I think that with Traumatic - orbital roof fracture, and traumatic lateral wall fracture that you see, the fat is gonna tamponade it, right? Most of the time, so CSF leak is not that
58:37
necessarily that much of the consideration. Pulsotile exothymos is a consideration, and I suppose that if a patient, let's say, after tumor resection has pulsotile exothymos, it's not like you've
58:48
necessarily burned any bridges. I see what you're saying that it's probably a good idea to go in and do it at the time and just get it done, but I don't, I think that we've had cases where we've
58:57
gone back later and put in hardware, and Goldberg has just kind of nailed in to us that the less hardware you put in there, the better, because I think over his career he's taken out a lot of
59:07
hardware. So I think that it's more of a style thing that we've kind of been indoctrinated into. I don't think there's any harm in it, especially when I end up with a patient like this who's
59:18
complaining of ocelopsia, you know, the sensation that the world is moving.
59:26
I guess in the case of, we talked about this in terms of meningiomas, how the, once you take out the sphenoid wing, do you reconstruct it? In that case, I guess the duros kind of thick, you
59:36
don't necessarily have to because they don't get as much pulsing. But in these cases where you do have pulsatile proptosis, maybe it is, it's something that you can come back later and do, I don't
59:46
know if I have a good answer for you. Yeah.
59:50
All right, if I want to leave in a five degree. Yeah. Yeah, cool Whoever wants to, yeah, Ken, whoever wants to learn. But thank you.
59:59
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