Neuro-ophthalmology

Department of ophthalmology,CMU4hOphthalmologic hospital,CMU

Optic nerve diseases

Optic nerve : consists of axons that arise from the ganglion cells, optic chiasm is its ending

Sheaths of optic nerve ： the fibrous wrapping that ensheathe the optic nerve are continuous with the meninges——dura 、 arachnoid and pia mater ；

Optic nerve diseases

Optic nerve diseases

Etiology ：

• 1.inflammation ： optic neuritis

• 2.Diseases of blood vessel ： ischemic optic neuropathy

• 3.Tumor ： optic glioma 、 meningioma of optic nerve

Optic neuritis

• Definition: Optic neuritis is inflammation 、 disintegration and demyelinaton of the optic nerve.

• Classify according to site ：Optic papillitis ： often seen in

childrenRetrobulbar neuritis ： often seen in

youth

Optic neuritis

Etiology ：• Myelinoclasis ： multiple sclerosis,optic

neuromyelitis.• Childhood Infections ：

measles 、 parotitis.• Infection of meninges 、 orbit or nasal

sinus.• Infection of eyeball ： retinitis 、 uveitis• Idiopathic ：

Optic neuritis

Clinical manifestations ：• Vision ： acute visual loss with the

nadir about 1 week after onset.• flare ， orbital pain, the pain is

exacerbated by eye movement.• Occasionally Uhthoff's sign (visual

deficit with exercise or increase in body temperature).

• Pupil: relative afferent pupillary defect (RAPD).

Optic neuritisClinical manifestations ：• Fundus: Swollen disc with or without

peripapillary flame-shaped hemorrhages. Fundus is normal in retrobulbar optic neuritis

• Visual field: central scotoma, concentric loss. • VEP: abnormal.

Optic neuritis

Differential diagnosis ：• 1.Ischemic optic neuropathy• 2.Leber’s optic neuropathy• 3.Toxic or metabolic optic

neuropathyTreatment ：• 1.Corticosteroid ：• 2.VitamineB ， Vasodilator ：

Anterior ischemic optic neuropathy

Definition: Anterior ischemic optic neuropathy is characterized by pallid disk swelling associated with acute loss of vision. The disorder is due to occlusion or decreased perfusion of the short posterior ciliary arteries.

Anterior ischemic optic neuropathy

Etiology ：1.Local vascular lesion of papilla 2.Hypotension of eye or total body3.Blood viscosity ↑4.High 5.Ocular hypertension

Anterior ischemic optic neuropathyClinical manifestation:symptoms ： sudden 、 painless 、 nonprogressive

visual loss.signs ：

vision ： moderate losspupil ： afferent pupillary defectFundus: pale disc swelling often involving only a

segment of the disc, flame-shaped hemorrhages, optic atrophy after the edema resolves

Visual field: altitudinal or central visual field defect

Clinical types ：Areritic Anterior ischemic optic neuropathy: due

to giant cell arteritis ：nonAreritic Anterior ischemic optic neuropathy

50 ～ 60 years

Anterior ischemic optic neuropathy

Differential diagnosis ： Optic neuritis ： Kennedy syndrom ：Treatment ：Treat systemic diseaseGeneral application of corticosteroidvasodilatorDecrease IOPOptic nerve sheath decompression

• Definition :Optic atrophy is a nonspecific response to optic nerve (retina to lateral geniculate body) damage from any cause.

• Etiology ：– Intracranial hypertension or inflammation– Retinopathy– Optic neuropathy– Compressive lesion– Trauma – Metabolic – Hereditary– Nutrient

Optic atrophy

Normal fudus Optic atrophy

Optic atrophy

Classification due to lesion site of fundus and optic nerve ：

• Primary optic atrophy ： or descending optic atrophy

• Secondary optic atrophy ： or ascending optic atrophy

Clinical manifestation ：Visual loss significantly ， visual

field concentric constriction

Optic atrophy

Optic atrophyPrimary optic atrophy

Secondary optic atrophy

Etiology Damage of visual path behind cribriform plate

Lesions of optic disc、 retina and choroid, et al.

Optic papilla pale ， clear border 、 screen mes can be seen in cup

Gray-white 、 dirty dark ， border not clear 、 physiological depression disappear

Vessel of retina

normal Narrow artery ， vessel with sheath

Diagnosis ：• According to fudus ,visual

acuity,visual field,VEP,CT,MRI et al.

Treatment ：• Treat primary disease• Assistant treatment： neurotrophic

medicine and vasodilator

Optic atrophy

Etiology ：1.intracranial ：

tumor 、 hemorrhage 、 edema 、 abscess2.Intraorbital ：

tumor 、 inflammation 、 Grave’s disease3.intraocular ： ocular hypotension 、 uveitis4.Systemic disease ： diabetes

mellitus 、 leukemia 、 malignant hypertension 、 pulmonary heart disease.

Papilledema

Papilledema

Pathogenesis ：

• Intracranial hypertension

• The theory of axoplasma flow

Clinical manifestaton ：• Symptoms ： Episodes of

transient, often bilateral, visual loss associated with psychiatric symptoms

• Visual field ： Enlarged physiological blind spot, lately concentric loss

Papilledema

Papilledema

Fundus ： four stages1. Early stage: hyperemic disc with blurring

of the disc margin, peripapillary retinal hemorrhages

2. Advanced stage: Bilaterally swollen, hyperemic discs with flame-like retinal hemorrhages 、 cotton-wool spots 、 macular hemorrhage and exudation.

3. Chronic stage ： prominence of disc, cup disappear ， and hard exudation

4. Atrophic stage ： pale papilla ， gliosis and narrowing of the retinal vessels

Papilledema

Differential diagnosis ：• Optic neuronitis• puedopapilledema• Leber’s optic neuropathy• Ischemic optic neuropathyTreatment ： • Treat according to causes ：• treat according to symptoms ： optic

nerve sheath decompression

Papilledema

Optic glioma

Meningioma of optic nervePapillary angioma

Papillary melanoma

Tumor of optic nerve

Papillary melanoma Papillary angioma

Tumor of optic nerve

Tumor of optic nerve

Optic glioma

Optic nerve hypoplasia Optic pit Optic disc drusen Coloboma of optic nerve Morning-glory syndrome

Abnormal development of optic disc

Abnormal development of optic disc

Optic pit

Abnormal development of optic disc

Morning-glory syndrome

Visual pathway ：Include:retina 、optic nerve 、optic chiasma 、optic tract 、lateral geniculate body 、optic radiation occipital cortex.

Optic chiasma and visual pathway diseases

Character: Hemianopia

homonymous hemianopsia heteronymous hemianopsia

Optic chiasma and visual pathway diseases

Hemianopia ： blindness in one-half

of the field of vision of one or both

eyes, is the characteristic of visual

pathway lesions.

Anatomical position of optic chiasma ： the optic chiasma is variably situated near the

top of the diaphragm of the sella turcica, the lamina terminalis forms the anterior wall of the third ventricle, the internal carotid A. lie just laterally, adjacent to the cavernous sinuses.

Etiology ： most diseases that affect the chiasma are

neoplastic, most common is pituitary tumors, next are tuberculum sella meningioma 、 craniopharyngioma 、 anterior communicating aneurysm 、 tumor of third ventricle.

Optic chiasma lesions

Clinical manifestation ： Blurred vision ： bilateral, simultaneously

or by turns Defect of visual field ： bitemporal

hemianopsia ， early, these defects are typically incomplete and are often asymmetric.

Abnormal ocular movement ： tumor offend cavernous sinus or superior orbital fissure

optic atrophy Symptoms of the primary diseaseTreatment ： treat primary disease.

Optic chiasma lesions

• Contralateral of lesion 、 bilateral homonymous hemianopia.• Wernicke’s hemianopia tonic pupil: when hemianopia side retina exposed to slit light ， pupil doesn’t constrict.• Lately, secondary optic atrophy may occur.

Optic tract lesions

Optic tract

Optic tract lesions

Lateral geniculate body lesions

Contralateral of lesion 、 bilateral homonymous hemianopia.

Lately, secondary optic atrophy may occur.

Optic radiation lesions Congruous bilateral homonymous

hemianopia Macular sparing Temporal crescent-shaped visual field loss No optic atrophy and Wernicke’s

hemianopia tonic pupil Accompany with symptoms of cerebrum

lesion

Occipital lobe lesions

Character: congruous bilateral homonymous hemianopia with sparing of the macula. No optic atrophy and Wernicke’s hemianopia tonic pupil. No phycotic symptoms.

Cortical blindness ： Bilateral occipital lobe infarctions

• Bilateral complete or severe loss of vision• Normal pupillary responses • Normal fundus and VEP

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