Neuro-ophthalmology sjtu ophthalmology 樊莹

Neuro-ophthalmology an important sensory end organ intimatedly related to the brain cranial nerves: 50％ II、III、IV、V、VI、VII cranial nerve fiber: 38％ intracranial diseases: 65％ vision loss blindness die diagnosis including etiology and location

optic neuropathy

structure of retina

nerve fiber layer

sensory visual pathway

anatomy of the optic nerve from optic disc to optic chiasm length：45~50mm including：intraglobe 1 mm intraorbit 25~30 mm optic canal 5 mm intracrania 10 mm

histology of the optic nerve comprised by ganglion cell axons covered by meninges (3 layers) lack of Schwann's cells hard to rebuild

to valuate optic nerve morphology：ophthalmoscope ultrasonic X-ray CT MRI function：vision acuity visual field pupil test VEP+ERG dark adaption colour perception

visual field testing steady fixation measure the comdined function of the retina “peripheral vision” <30°central visual field >30°peripheral visual field

kinetic perimetry

static perimetry

electrophysiologic testing electrooculogram EOG electroretinogram ERG visual evoked potential VEP

pupil

light reflex normal abnormal

optic neuropathy inflammatory： optic neuritis vascular： anterior ischemic optic neuropathy (AION) neoplastic infiltration： glioma, leukaemia, lymphoma, meningeal carcinomatosis others： optic atrophy、papilledema

Optic neuritis duo to a variety of causes the most common is demyelination else: immune-mediated direct infections granulomatous optic nueropathy contiguous inflammatory disease

demyelinative optic neuritis clinical features: chiefly in women(3:1) chiefly in white associated with multiple sclerosis subacute(2~7days) color vision and contrast sensitivity impaired pain(in eye 90%)(by eye movement 50%) abmormal in pupil testing change in VEP a central scotoma in most cases brain MRI (necesssary) including: papillitis retrobulbar neuritis

Papillitis in 35% cases hyperemia of the optic disk and large veins(early signs) edema (nearly more than 3D) (common) blurring of the disk margins (common) filling of the physiologic cup (common) retinal exudates and edema (uncommon) hemorrhage (uncommon) vitreous cells (uncommon)

Papillitis Fundus

Papillitis FFA

Papillitis CT Visual field

Retrobulbar neuritis vision loss no obvious changes in the optic disk (at earlier stage) secondary optic atrophy

demyelinative optic neuritis differential diagnosis: compressive optic neuropathy anterior ischemic optic neuropathy autoimmune optic neuropathy toxic amblyopia Leber's hereditary optic neuropathy vitamin B12 deficiency papilledema

demyelinative optic neuritis treatment: steroid therapy can accelerate recovery of vision can not influence the ultimate visual outcome may increase the risk of recurrency intravenous steroid therapy useful for multiple sclerosis

anterior ischemic optic neuropathy (AION) due to infarction of the retrolaminar optic nerve from occlusion or decreased perfusion of the short posterior ciliary arteries

vessels of the optic nerve

AION causes: arteriosclerosis diabetes hypertension hyperlipidemia intracranial stroke vasculitis,migraine,inherited prothrombotic states(in younger patients) reduced cup,optic nerve head drusen,increased intraocular pressure

AION clinical features: in the sixth or seventh decade vision loss without pain generally abrupt,progressive altitudinal vision field defects() FFA:decreased perfusion segmented the nonarteritic form diffuse the arteritic form disk leakage the late phase

AION

AION

AION treatment: No treatment has been shown to provide long-term benefit. Low-dose aspirin may reduce the risk of involvement of the fellow eye. identify the arteritic AION (high-dose systemic steroids)

Papilloedema noninflammatory congestion due to raised intracranial pressure causes intracranial mass abscesses subdural hematoma arteriovenous malformation subarachnoid hemorrhage meningitis or encephalitis acquired hydrocephalitis else

Papilledema increased intracranial pressure axonal transpot is blocked

Papilledema clinical features: normal vision in most cases for early papilledema 1~2days to occur and 1 week to develop fully severe vision loss for late papilledema

Papilledema the early stage

papilledema the middle stage

papilledema the late stage

papilledema FFA

papilledema differential diagnosis: burid drusen of the optic nerve small hyperopic disks AION myelinated nerve fibers

papilledema treatment: deal with the underlying cause

Optic atrophy primary optic atrophy secondary optic atrophy

primary secondary + - papilledema axonal fiber atrophy proliferation of glia - pale disk papilledema blurring of margin retinal vessels normal abnormal

Optic atrophy

Optic atrophy treatment: to the underlying cause

optic nerve tumor glioma of optic nerve meningioma of optic nerve

Glioma of optic nerve

Glioma of optic nerve

Meningioma of optic nerve

Meningioma of optic nerve

optic nerve tumor treatment: operation

the optic chiasm

视交叉病变

the optic chiasm diseases pituitary adenoma craniopharyngioma tuberculum sellae meningioma chiasmatic and optic nerve gliomas

pituitary adenoma

the retrochiasmatic visual pathways cortical blindness macular sparing macular splitting

cases