CLINICAL SERVICES - NEURO-OPHTHALMOLOGY
OUR CLINICAL SERVICES: WHAT WE DO
The Neuro-ophthalmologic service treats 3,000 patients a year with neuro-ophthalmic conditions. These conditions range from visual loss and double vision problems to eyelid droops and spasms.
Conditions seen include:
▶ Visual loss due to optic neuropathies including:
- Ischaemic optic neuropathy
- Optic neuritis
- Compressive optic neuropathy
- Inflammatory and infectious optic neuropathies
- Hereditary optic neuropathy
▶ Double vision or diplopia due to:
- Cranial nerve palsies
- Myasthenia gravis
- Thyroid eye disease
- Other myopathies (eye muscle disorders)
▶ Transient visual loss:
- Migraine
- Clot or emboli affecting blood supply to the visual pathway (including transient ischaemic attack or TIA)
- Abnormal blood vessel formation within the brain affecting the visual pathway (arterio-venous malformation)
- Papilloedema (raised pressure in the brain, leading to swelling of the optic discs)
▶ Visual loss resulting from stroke or other brain disorders
▶ Unexplained visual loss
▶ Asthenopia or eye strain
▶ Pupillary abnormalities
▶ Droopy eyelids (ptosis)
▶ Facial nerve palsies
▶ Spasms including:
- Eyelid myokymia
- Hemifacial spasm
- Benign essential blepharospasm
Neuro-ophthalmologic evaluation
a) General neuro-ophthalmology clinic
- Thorough medical history-taking
- Neuro-ophthalmic examination
- Formal visual field testing (Bjerrum, Goldmann and Humphrey perimetry) when indicated
- Orthoptic assessment for patients with double vision or asthenopia
- Relevant investigations as guided by the above
Initial investigations will often indicate either the diagnosis or that further investigations are required, and this is explained to the patient.
Investigations and procedures that may be performed:
- Ice test
- Prostigmin test
- Contrast sensitivity testing
- Fundus fluorescein angiogram, fundus photography, stereo disc photos
- B-scan ultrasound
- Optical coherence tomography (OCT)
- Electrophysiology testing (visual evoked potential (VEP) including multifocal VEP, pattern electroretinogram (PERG), full-field ERG, multifocal ERG)
- Blood investigations
- Mantoux test
- Temporal artery biopsy
The following tests are performed at the Singapore General Hospital (within the same campus):
- Neurophysiologic tests: single fibre electromyography, repetitive nerve stimulation, nerve conduction studies
- Carotid ultrasound, anterior and posterior transcranial Doppler studies
- Neuroimaging: Computed Tomography (CT) orbit / brain, CT angiogram; Magnetic Resonance Imaging (MRI) orbit / brain, MR angiogram, MR venogram; cerebral angiogram
- Sleep study (for suspected obstructive sleep apnoea in cases of ischaemic optic neuropathy or pseudotumour cerebri)
b) Pituitary clinic
This weekly clinic is held in combination with a neurosurgeon from the National Neuroscience Institute who has expertise in performing endoscopic transphenoidal resection of pituitary tumours. Patients are counselled and listed for surgery by trained staff at the SNEC for surgery to be performed at the adjacent Singapore General Hospital. Post-surgery, the patient is followed-up in the same pituitary clinic.
Treatment
Outpatient treatment includes:
- Medical treatment of ocular myasthenia gravis
- Management of double vision with prism or Bangerter foil (varying grades of occlusive covering over one spectacle lens)
- Management of asthenopia through various orthoptic exercises, including exercises for convergence insufficiency and accommodation infacility
- Injections for hemifacial spasm, blepharospasm and persistent eyelid myokymia
- For certain cases of long-term double vision, injections into an eye muscle may be an appropriate form of management. Such patients are referred to the paediatric ophthalmology service for this treatment
- Low vision clinic: this is a separate service within SNEC to which patients with severe visual loss are referred for further assessment, visual aids, support and referral to the Singapore Association of the Visually Handicapped
Inpatient treatment includes:
- Inpatient medical treatment of conditions such as optic neuritis
- Optic nerve sheath decompression (with co-management by the Orbital Service)
- Neurosurgical intervention
- Interventional neuroradiologic treatment of vascular problems such as carotid cavernous sinus fistula and cerebral aneurysm
Multidisciplinary approach
Management of a neuro-ophthalmologic condition frequently necessitates the involvement of other neuroscience disciplines, such as neurosurgery, neurology and neuroradiology. Patients referred to the Neurosurgery department at Singapore General Hospital (SGH) have the added advantage that SGH is the first hospital worldwide (http://www.nni.com.sg/Newsroom/MediaRelease/NeuroscienceCentre.htm) to offer the full range of intraoperative imaging (MRI, CT, 3D C-arm) by Brain LAB, which allows the surgeon to look at the precise images of a patient's brain before, during and immediately after surgery. This allows the surgeon to decide whether further procedures are required and translates to better outcome for the patient. Some of our patients have tumours compressing the optic nerve or an ocular motor nerve causing double vision that are deemed too risky for surgery. In many of these cases, Novalis stereotactic radiosurgery, also available at SGH, is given instead, where precise focused shaped beams of high-energy radiation are directed at the tumour while limiting damage to surrounding normal tissue. (http://www.nni.com.sg/Newsroom/MediaRelease/Novalis+News.htm)
Conditions such as carotid cavernous sinus fistula and cerebral aneurysm are co-managed with the neurosurgery and interventional neuroradiology department at SGH.
We also co-manage patients with other specialties including otolaryngology, endocrinology, rheumatology, infectious diseases and oncology.
Please visit the following relevant links:
Neuro-Ophthalmology Clinical Staff
I Want an Eye Examination / an Appointment
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Read more on related Eye Conditions and Treatments:
Double Vision (Diplopia)
Ischaemic Optic Neuropathy
Optic Neuritis
Spasms