1. Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery
9/19/2018

2. … nothing to disclothes …
Howard R Krauss, MD
Los Angeles, CA

3. Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery
Pacific Eye & Ear
11645 Wilshire Blvd., Suite 600
Los Angeles, Ca
Howard R Krauss, MD
Neuro-ophthalmology
Strabismus
Orbital Surgery
9/19/2018

4. pacific eye & ear
Pacific Eye & Ear is an association of eleven doctors, providing medical and surgical services encompassing Ophthalmology, ENT, Facial Plastic Surgery and Audiology.
9/19/2018

5. Diagnostic approaches to reduced vision
1) Talk with and examine the patient
9/19/2018

6. Diagnostic approaches to reduced vision
When the vision is subnormal, proceed to: 2) Pinhole acuity 3) Refraction 4) Visual field assessment
9/19/2018

7. Diagnostic approaches to reduced vision
If 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.
9/19/2018

8. Diagnostic approaches to reduced vision
If corrected acuity is abnormal or visual field is abnormal: 1) Proceed with Retinal Evaluation and/or consultation.
9/19/2018

9. Diagnostic approaches to reduced vision
If 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.
9/19/2018

10. Diagnostic approaches to reduced vision
If 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.
9/19/2018

11. Diagnostic approaches to reduced vision
If 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.
9/19/2018

12. Diagnostic approaches to reduced vision
If 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.
9/19/2018

13. Diagnostic approaches to reduced vision
If 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.
9/19/2018

14. Diagnostic approaches to reduced vision
If 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.
9/19/2018

15. Diagnostic approaches to reduced vision
If 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.
9/19/2018

16. Diagnostic approaches to reduced vision
If 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.
9/19/2018

17. Ocular Coherence Tomography (OCT) Neuro-ophthalmic Applications
Evaluation and Monitoring:
MS / Optic Neuritis
Ischemic Optic Neuropathy
Any Optic Neuropathy
Compressive Optic Neuropathy
Papilledema

18. 55-year-old woman with MS BCVA 20/30 OD 20/25 OS

19. 47-year-old Hawaiian woman
Aware of diminishing vision of the left eye over 1 year, rapidly worsening over the last 3 months.
Intermittent mild pain OS, especially when flying.
47-year-old Hawaiian woman

20. Visual Acuity 20/25 OD 20/50-1 OS No proptosis No enophthalmos
No hyper- or hypoglobus
Orthophoric in all positions
Full ductions
2+ RAPD OS
Visual Acuity 20/ OD /50-1 OS

21. Humphrey

22. Octopus

23. RNFL thkns 106 OD, 93 OS

25. Transnasal 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.
9/19/2018

26. Outpatient Surgery

27. Image-guided Endoscopic Sx

30. Pre-op / Octopus / Post-op

31. Post-op

32. 2 weeks post-op UCVA 20/25 Trace RAPD OS
Mild weakness of left adduction and infraduction – improving day- by-day
2 weeks post-op

35. mri of the visual afferent system
Brain and Orbits with and without contrast
9/19/2018

36. mri of the visual afferent system
If you know the lesion is retrogeniculate:
Brain with and without contrast
9/19/2018

37. mri of the visual afferent system
If you know the lesion is anterior visual pathway:
Orbits and pituitary with and without contrast
9/19/2018

38. BSB 54yo female
11/05: Puffiness OS
Va 20/15,20/25
Ext: H 16/21
P: 1.2log LAPD
EOM: min ↓ L elev

39. BSB – W/U
OCT NFL (11/05):

40. BSB – W/U
MRI (12/05):

41. BSB – F/U
MRI (5/06):

42. BSB – F/U
10/06: Diplopia in
right gaze
Va 20/20 OU
Ext: H 16/14
EOM: min ↓ L add
P: .3log LAPD

43. BSB – W/U
OCT NFL (10/06):

44. JWD 63yo male
3/06: ↓Va OS
Va 20/20,20/60
P: .9log LAPD

45. JWD – POH
12/05: Routine check vision
Dx: “cataracts”
Referred for cataract extraction
Ophthalmologist said “no cataract”

46. JWD – W/U
OCT:

47. JWD – F/U
8/07: “No Δ”
Va 20/25 OU
P: .9log LAPD

48. JWD – W/U
OCT NFL (8/07):

49. KH 48yo female 11/08: ↓Va Va 20/30,8/200 VF: Ext: w/q P: .3log LAPD
EOM: full
SLE: wnl
Fundus: nl DMV
9/19/2018

50. KH – PMH 1/08: Polydipsia 4/08: Amenorrhea 10/08: HA, N/V
9/19/2018

51. KH – W/U
OCT NFL (11/08):
9/19/2018

52. KH – W/U
MRI (11/08):
9/19/2018

53. 11/08: Transphenoidal endoscopic decompression Path: craniopharyngioma
KH – Rx
11/08: Transphenoidal endoscopic decompression
Path: craniopharyngioma
9/19/2018

54. KH – 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:
9/19/2018

55. KH – W/U
OCT NFL (8/09):
9/19/2018

56. In 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.

57. Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery
Pacific Eye & Ear
11645 Wilshire Blvd., Suite 600
Los Angeles, Ca
Howard R Krauss, MD
Neuro-ophthalmology
Strabismus
Orbital Surgery
9/19/2018