Chapter 45 Patients with neurologic and neurosurgical diseases commonly present to the emergency room (ER) with neuro-ophthalmologic symptoms and signs, as most patients are very sensitive to any change in their visual function. This chapter focuses on the diagnoses requiring an emergent workup and treatment. For further details on these diseases, refer to previous chapters. 1. Does the visual loss involve one eye or both eyes? 2. If the visual loss is binocular, and no ocular abnormalities are seen, it is most likely related to a lesion involving the intracranial visual pathways such as the chiasm or retrochiasmal visual pathways (Tables 45–1 and 45–2), and the patient should be evaluated emergently by a neurologist. Neuroimaging [brain magnetic resonance imaging (MRI) with gadolinium or diffusion-weighted imaging, depending on the clinical presentation, or at least head computed tomography (CT) without and with contrast] should be obtained immediately. 3. Unilateral visual loss is most often secondary to ocular diseases, and a complete ophthalmological evaluation should be performed emergently by an ophthalmologist. 4. Transient monocular visual loss is often related to ischemic vascular diseases and may herald permanent visual loss and devastating cerebral infarction (Tables 45–3 and 45–4; Fig. 45–1). 5. Presume that all elderly patients with acute visual loss could have giant cell arteritis and examine them promptly. Up to 25% of patients with visual loss from giant cell arteritis do not have any systemic symptoms. Because giant cell arteritis can strike the fellow eye within hours or days after visual loss, the diagnosis of giant cell arteritis is urgent. Workup and treatment with corticosteroids should be initiated in the ER.
NEURO-OPHTHALMIC EMERGENCIES
BROAD CATEGORY 1: “I CANNOT SEE”
QUESTIONS TO ASK AND POINTS TO KEEP IN MIND
Bilateral (persistent when the patient closes one eye) Ocular: transient visual obscuration (bilateral optic nerve head swelling) Hyperglycemia Cataracts Bilateral hypertensive or diabetic retinopathy Bilateral optic neuropathy Intracranial visual pathways Bitemporal homonymous hemianopia (chiasma) Homonymous hemianopia (retrochiasmal visual pathways) Bilateral homonymous hemianopia or cerebral blindness (bilateral occipital lobes) Unilateral Ocular disease Optic neuropathy |
Bilateral occipital infarction Superior sagittal venous sinus thrombosis Cerebral hypoxia Dural fistula Occipital arteriovenous malformation Head trauma Hypertensive encephalopathy Eclampsia Cyclosporine/FK-506 Carbon monoxide intoxication Mitochondrial encephalopathy, lactate acidosis, stroke-like episodes (MELAS) Migraine |
Red Flag
Visual loss present for more than 1 month may reflect a compressive lesion, but rarely needs emergent consultation.
BROAD CATEGORY 2: “MY EYELID IS DROOPY”
QUESTIONS TO ASK AND POINTS TO KEEP IN MIND
1. A unilateral or bilateral ptosis of more than 1 to 2 mm may be secondary to a lesion involving the eyelid levator muscle (senile ptosis, myopathies), the neuromuscular junction (myasthenia), or the oculomotor nerve (third cranial nerve).
2. New-onset ptosis should alert the clinician to look for a third nerve palsy. A patient may not complain of diplopia because the ptosis covers the visual axis or there is visual loss in one eye. Careful examination should be performed to look for ocular motor paresis and anisocoria.
3. One cause of “mild ptosis,” usually 2 mm or less, is Horner’s syndrome, in which the palpebral fissure is reduced. It is the pupillary examination demonstrating ipsilateral miosis that confirms the diagnosis of Horner’s syndrome.
Vascular (“amaurosis fugax”) Retinal ischemia Central and branch retinal arteries Central and branch retinal veins Choroidal ischemia Posterior ciliary arteries Optic nerve ischemia Posterior ciliary arteries Ocular ischemia Ophthalmic artery ? Migraine Optic nerve head swelling Anomalous disc Disc drusen Congenital disc anomalies Optic nerve compression (orbital mass) Uhthoff’s phenomenon Lacrimal disorders (dry eyes) Keratoconus Corneal edema Hyphema Intermittent angle closure glaucoma Serous retinal detachment |
Red Flags
Isolated ptosis without diplopia or anisocoria is usually not an emergency.
Ocular myopathies rarely present emergently.
Ocular myasthenia is not a therapeutic emergency, unless the patient has symptoms and signs suggestive of systemic myasthenia such as respiratory distress or dysphagia.
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