Neuroophthalmology Strabismus Orbital Surgery 412015 wwwPacificSpecialistscom nothing to disclothes Howard R Krauss MD Los Angeles CA neuroop Howard R Krauss MD ID: 918004
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Slide1
neuro-op
Howard R Krauss, MDNeuro-ophthalmologyStrabismusOrbital Surgery
4/1/2015
www.PacificSpecialists.com
Slide2… nothing to disclothes …
Howard R Krauss, MDLos Angeles, CA
Slide3neuro-op
Howard R Krauss, MDNeuro-ophthalmologyStrabismusOrbital Surgery
4/1/2015
www.PacificSpecialists.com
Pacific Eye & Ear
11645 Wilshire Blvd., Suite 600
Los Angeles, Ca. 90025
310-477-5558
DrKrauss@PacificSpecialists.com
www.PacificSpecialists.com
Slide4pacific eye & ear
4/1/2015 www.PacificSpecialists.com
Pacific Eye & Ear is an association of eleven doctors, providing medical and surgical services encompassing Ophthalmology, ENT, Facial Plastic Surgery and Audiology.
Slide5Diagnostic approaches to reduced vision1) Talk with and examine the patient
4/1/2015www.PacificSpecialists.com
Slide6Diagnostic approaches to reduced visionWhen the vision is subnormal, proceed to:
2) Pinhole acuity 3) Refraction 4) Visual field assessment4/1/2015www.PacificSpecialists.com
Slide7Diagnostic approaches to reduced visionIf corrected acuity is normal
and visual field is normal: 1) Complete the general examination and if all else is normal, proceed to discussion of optical services, from spectacles to contact lenses to surgery.4/1/2015www.PacificSpecialists.com
Slide8Diagnostic approaches to reduced visionIf corrected acuity is abnormal or visual field is abnormal:
1) Proceed with Retinal Evaluation and/or consultation.4/1/2015www.PacificSpecialists.com
Slide9Diagnostic approaches to reduced visionIf Retinal Consultant detects abnormalities and arranges treatment for same:
1) Re-evaluate patient to assess whether or not the retinal abnormalities are likely the only source of the patient’s complaints.4/1/2015www.PacificSpecialists.com
Slide10Diagnostic approaches to reduced visionIf Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, crystalline lens, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG 7
) Consider Neuro-ophthalmologic consultation.4/1/2015
www.PacificSpecialists.com
Slide11Diagnostic approaches to reduced visionIf Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG 7) Consider Neuro-ophthalmologic consultation.
4/1/2015
www.PacificSpecialists.com
Slide12Diagnostic approaches to reduced visionIf Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG 7) Consider Neuro-ophthalmologic consultation.
4/1/2015
www.PacificSpecialists.com
Slide13Diagnostic approaches to reduced visionIf Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG 7) Consider Neuro-ophthalmologic consultation.
4/1/2015
www.PacificSpecialists.com
Slide14Diagnostic approaches to reduced visionIf Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG 7) Consider Neuro-ophthalmologic consultation.
4/1/2015
www.PacificSpecialists.com
Slide15Diagnostic approaches to reduced visionIf Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG 7) Consider Neuro-ophthalmologic consultation.
4/1/2015
www.PacificSpecialists.com
Slide16Diagnostic approaches to reduced visionIf Retinal Consultant finds the retina to be normal, re-evaluate patient:
1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses
6) Consider ERG 7
) Consider Neuro-ophthalmologic consultation.
4/1/2015www.PacificSpecialists.com
Slide17Ocular Coherence Tomography (OCT)Neuro-ophthalmic Applications
Evaluation and Monitoring: MS / Optic Neuritis Ischemic Optic Neuropathy Any Optic Neuropathy Compressive Optic Neuropathy Papilledema
Slide1855-year-old womanwith MSBCVA 20/30 OD 20/25 OS
Slide1947-year-old Hawaiian womanAware of diminishing vision of the left eye over 1 year, rapidly worsening over the last 3 months.Intermittent mild pain OS, especially when flying.
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Slide20Visual Acuity 20/25 OD 20/50-1 OS
No proptosisNo enophthalmosNo hyper- or hypoglobusOrthophoric in all positionsFull ductions2+ RAPD OS
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Slide21Humphrey 10-26-11
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Slide22Octopus 12-27-11
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Slide23RNFL thkns 106 OD, 93 OS
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Slide24www.PacificSpecialists.com
Slide25Transnasal Image-Guided Orbital Surgery (TIGOS) TIGOS has been carried out by
Drs. Krauss & Griffiths since 2001. The work was presented at the 5th International Congress of the World Federation of Skull Base Societies in 2008.
4/1/2015
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Slide26Outpatient Surgery
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Slide27Image-guided Endoscopic Sx
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Slide28www.PacificSpecialists.com
Slide29www.PacificSpecialists.com
Slide30Pre-op / Octopus / Post-op
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Slide31Post-op
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Slide322 weeks post-op
UCVA 20/25Trace RAPD OSMild weakness of left adduction and infraduction – improving day-by-day
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Slide33www.PacificSpecialists.com
Slide34www.PacificSpecialists.com
Slide35mri of the visual afferent systemBrain and Orbits with and without contrast
4/1/2015www.PacificSpecialists.com
Slide36mri of the visual afferent systemIf you know the lesion is
retrogeniculate:Brain with and without contrast4/1/2015www.PacificSpecialists.com
Slide37mri of the visual afferent systemIf you know the lesion is anterior visual pathway:
Orbits and pituitary with and without contrast4/1/2015www.PacificSpecialists.com
Slide38BSB 54yo female
11/05: Puffiness OS
Va 20/15,20/25
Ext: H 16/21
P: 1.2log LAPD
EOM: min
↓ L elev
Slide39BSB – W/U
OCT NFL (11/05):
Slide40BSB – W/U
MRI (12/05):
Slide41BSB – F/U
MRI (5/06):
Slide42BSB – F/U
10/06: Diplopia in
right gaze
Va 20/20 OU
Ext: H 16/14
EOM: min
↓ L add
P: .3log LAPD
Slide43BSB – W/U
OCT NFL (10/06):
Slide44JWD 63yo male
3/06:
↓Va OS
Va 20/20,20/60
P: .9log LAPD
Slide45JWD – POH
12/05: Routine check vision
Dx: “cataracts”
Referred for cataract extraction
Ophthalmologist said “no cataract”
Slide46JWD – W/U
OCT:
Slide47JWD – F/U
8/07: “No
Δ
”
Va 20/25 OU
P: .9log LAPD
Slide48JWD – W/U
OCT NFL (8/07):
Slide49KH 48yo female
11/08:
↓Va
Va 20/30,8/200
VF:
Ext: w/q
P: .3log LAPD
EOM: full
SLE: wnl
Fundus: nl DMV
4/1/2015
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Slide50KH – PMH
1/08: Polydipsia
4/08: Amenorrhea
10/08: HA, N/V
4/1/2015
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Slide51KH – W/U
OCT NFL (11/08):
4/1/2015
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Slide52KH – W/U
MRI (11/08):
4/1/2015
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Slide53KH – Rx
11/08:
Transphenoidal
endoscopic decompression
Path:
craniopharyngioma
4/1/2015
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Slide54KH – F/U
8/09: “Better”
Va 20/20 OU
N 3pt OU
VF:
Ext: w/q
P: w/o APD
EOM: full
SLE: wnl
Ta: 19/22
Fundus:
4/1/2015
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Slide55KH – W/U
OCT NFL (8/09):
4/1/2015
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Slide56In summary:Listen
to the patient and solicit information.Examine the patient: determine BCVA and assess VF.Understand and explain symptoms and findings.Consider and recommend additional testing, or consultation, as indicated.Follow-up on all tests and consultations with patient.
Avoid contributing to a delay in diagnosis and treatment.
Slide57neuro-op
Howard R Krauss, MDNeuro-ophthalmologyStrabismusOrbital Surgery
4/1/2015
www.PacificSpecialists.com
Pacific Eye & Ear
11645 Wilshire Blvd., Suite 600
Los Angeles, Ca. 90025
310-477-5558
DrKrauss@PacificSpecialists.com
www.PacificSpecialists.com