common visual disorders

NERVOUS II

COMMON EYE DISORDERS

อ.พ.ญ.ลนิดา หรรษภญิโญ

อ. พ.ญ. เจนจติ ชูวุฒยากร

ภาควชิาจกัษุวทิยา คณะแพทยศาสตร ์มหาวทิยาลยัเชยีงใหม่

1. Understand basic pathology of

the neural eye disorders

2. Explained basic symptoms

3. Primary management or

suggestion

LEARNING OBJECTIVES

1. Understand basic pathology of

the neural eye disorders

2. Explained basic symptoms

3. Primary management or

suggestion

LEARNING OBJECTIVES

Optic disc edema

Pupillary abnormalities

Eye with systemic disease

VISUAL FUNCTIONS: VISUAL ACUITY

VISUAL FUNCTIONS: COLOR VISION

Ishihara plate Farnsworth D-15

Farnsworth-Munsell 100

VISUAL FUNCTIONS: CONTRAST SENSITIVITY

VISUAL FUNCTIONS: CONTRAST SENSITIVITY

SPECIAL TESTS

Visual field

Electrophysiology: VEP (visual evoked

potential), ERG (electro retinogram)

Imaging study: CT, MRI, angiography

VISUAL PATHWAY

AND

VISUAL FIELD

VISUAL PATHWAY

Optic nerve

Optic chiasm

Optic tract

Lateral geniculate body (LGB)

Anterior visual pathway

VISUAL PATHWAY

Optic radiation

Visual cortex (Occipital Lobe)

Posterior visual pathway

VISUAL FIELD

VISUAL FIELD

NORMAL VISUAL FIELD

Extension :

60 degree nasal & above

70 degree below

90 degree temporal

ABNORMAL VISUAL FIELD

OPTIC NERVE LESION

CHIASMAL LESION

Bitemporal hemianopia

CHIASMAL LESION

CHIASMAL LESION

OPTIC TRACT LESION

Contralateral

Homonymous field defects

Incongruous hemianopia

RETROGENICULATE LESION

Contralateral

Homonymous field defects

More posterior...

more congruous

OPTIC RADIATION LESION

Contralateral

Quadrantanopia

Temporal

Lobe Lesion

Parietal

Lobe Lesion

OCCIPITAL LOBE LESION

Contralateral

Complete

Homonymous hemianopia

OCCIPITAL LOBE LESION

Contralateral

Complete

Homonymous hemianopia

CONCLUSIONS

Prechiasmal lesion:

monocular field defect

Chiasmal lesion:

bitemporal field defect

Postchiasmal lesion:

homonymous field defect

OPTIC DISC EDEMA

CAUSES

Increased intracranial pressure: Papilledema

Inflammation:

Optic neuritis (papillitis) Ischemia:

Anterior ischemic optic neuropathy(AION)

Compression: Orbital tumors

CAUSES

Increased intracranial pressure: Papilledema

Inflammation:

Optic neuritis (papillitis)Ischemia:

Anterior ischemic optic neuropathy(AION)

Compression: Orbital tumors

Normal

discSwollen

disc

Headache

Vomiting

Transient visual loss

Double vision(diplopia)

Optic disc edema

Hyperemia and dilatation of surface capillaries

Edema of surrounding retina

CN VI palsies

Normal vision(acute)

SYMPTOMS AND SIGNS

SYMPTOMS AND SIGNS

UNCAL HERNIATION:CN VI PALSY

STAGING

Acute papilledema:

normal visual function

Chronic Papilledema:

loss of visual function

CAUSES

Increased intracranial pressure: Papilledema

Inflammation:

Optic neuritis (papillitis)Ischemia:

Anterior ischemic optic neuropathy(AION)

Compression: Orbital tumors

OPTIC NEURITIS

Acute/subacute visual loss

Retrobulbar pain / worse on eye

movement

15-45 y, women predominately

RAPD

Color deficit

OPTIC NEURITIS

OPTIC NEURITIS

2/3 of patients is retrobulbar (normal optic

disc) ,1/3 is papillitis (disc edema)

Most cases recover vision gradually

OPTIC NEURITIS

demyelination*(MS)

systemic infection

adjacent infection

vaccination

OPTIC NEURITIS

Oral prednisolone: placebo, increase rate of

recurrent

IV methylprednisolone followed by oral

prednisolone:faster recovery, but final VA at

6 months did not different from placebo.

ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)

An infarction of the optic nerve head caused

by inadequate perfusion by the posterior

ciliary artery

Onset of visual loss is sudden and usually

painless

ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)

Arteritic type

Non arteritic type

ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)

Non arteritic type

COMPRESSIVE OPTIC NEUROPATHY

PUPILLARY PATHWAY

PUPILLARY PATHWAY

Parasympathetic pathway Sympathetic pathway

ABNORMAL PUPILLARY RESPONSE

Relative Afferent Pupillary Defect

(RAPD)

Anisocoria

ABNORMAL PUPILLARY RESPONSE

Relative Afferent Pupillary Defect (RAPD)

Marcus Gunn pupil

Defect in direct light reflex but

preserve concentual light reflex

ABNORMAL PUPILLARY RESPONSE

Relative Afferent Pupillary Defect (RAPD)

ABNORMAL PUPILLARY RESPONSE

RAPD positive

Unilateral anterior visual pathway

Bilateral anterior visual pathway (asym.)

RAPD negative

Bilateral anterior visual pathway (sym.)

Posterior visual pathway

Relative Afferent Pupillary Defect (RAPD)

http://www.ohiolionseyeresearch.com/eye-center/glossary/anisocoria/

Anisocoria

4 mm 3 mm

Anisocoria

Anisocoria greater in dim light

4 mm 3 mm 5 mm 3 mm

Anisocoria

Anisocoria greater in dim light

4 mm 3 mm 5 mm 3 mm

Anisocoria

Anisocoria greater in dim light

4 mm 3 mm 5 mm 3 mm

4 mm 3 mm

Anisocoria

Anisocoria greater in dim light

4 mm 3 mm 5 mm 3 mm

4 mm 3 mm 4 mm 2 mm

Anisocoria

Anisocoria greater in dim light

4 mm 3 mm 5 mm 3 mm

Anisocoria greater in bright light

4 mm 3 mm 4 mm 2 mm

Anisocoria

physiologic anisocoria

large pupil affected

- oculomotor nerve palsy with pupil involvement

- tonic pupil - pharmacologic - traumatic iris damage

small pupil affected

- Horner’s syndrome

- posterior synechiae - pharmacologic

Anisocoria

ptosis (levator palpebral m)

ocular movement limitation (SR, IR, MR, IO)

pupil dilatation with sluggish react to light

Oculomotor nerve palsy

http://bombayoculoplastics.com/nerve%20palsies.htm

congenital

acquired

- pupil sparing: Ischemia (DM, HT, dyslipidemia..)

- pupil involvement: compression (aneurysm, tumor)

Oculomotor nerve palsy

deficiency of oculosympathetic activity

1. miosis

2. ptosis (mild-moderate)

3. anhidosis

Horner’s syndrome

http://www.pediatricsconsultant360.com/content/horner-syndrome

Second-order neuron(Preganglionic)

First-order neuron(Central)

Third-order neuron(Postganglionic)

diagnose & localize lesion: - associated signs and symptoms

Horner’s syndrome

Clinical Applications

Painless Visual Loss

Central retinal vein occlusion

Central retinal artery occlusion

Ischemic optic neuropathy

Cerebral stroke

Painful Visual Loss

Optic neuritis

Glaucoma

Infection: conjunctivitis, corneal ulcer etc.

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

Central Retinal Arterial Occlusion:

Predisposing factors:

Atherosclerosis

DM, HT, Hyperlipidemia,

Aging, smoking

Cardiac emboli

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

Central retinal arterial occlusion

Branch retinal arterial

occlusion

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

Treatment

Ocular massage

Cabogen (95% oxygen, 5% cabon

dioxide)

Decreased intraocular pressure

Medication

tapping

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

Central Retinal Vein Occlusion

Venous compression and thrombosis

Predisposing factors:

Aging, DM, HT, Hyperlipidemia

Hypercoagulative states,

myeloproliferative disorders

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

Branch retinal vein occlusion

Central retinal vein occlusion

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

Treatment

Observation

Neovascularization, macular edema

Laser photocoagulation

Intravitreal anti vascular endothelial

growth factor (anti-VEGF)

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

ตามัวฉับพลัน (ACUTE VISUAL LOSS)

Optic neuritis:

จอตาผิดปกติ (Retinopathy)

จุดภาพชัดผิดปกติ (Maculopathy)

ต้อกระจก (Cataract)

ต้อหิน (Glaucoma)

สายตาผิดปกติ (Refractive error)

CHRONIC VISUAL LOSS

Keratitis

Cataract

Retinal abnormalities: retinoblastoma, retinal detachment

Vitreous abnormalities: vitreous hemorrhage

Retinopathy of prematurity

WHITE PUPIL (LEUKOCORIA)

PATIENT

History of cataract surgery

Acute blurred vision: 1 day

Old age: 56 years

Red eye

Pain

ACUTE PAINFUL VISUAL LOSS

ACUTE PAINFUL VISUAL LOSS

Endophthalmitis: Endogenous

Post surgery

Trauma

ACUTE PAINFUL VISUAL LOSS

Treatment

Antibiotics: systemic, intravitreal injection

Surgery

PATIENT

Distorted vision

AMSLER GRID TEST

CHRONIC PROGRESSIVE VISUAL LOSS

Epiretinal membrane:

CHRONIC PROGRESSIVE VISUAL LOSS

Macular hole:

CHRONIC PROGRESSIVE VISUAL LOSS

Treatment

surgery

Hypertensive retinopathy

arteriovenous nicking

cotton wool spot

retinal hemorrhage

Chronic Progressive Visual Loss

Treatment: observe, laser

Chronic Progressive Visual Loss

CHRONIC PROGRESSIVE VISUAL LOSS

Diabetic retinopathy

CHRONIC PROGRESSIVE VISUAL LOSS

Treatment

Controlled blood sugar

Macular edema: laser, intravitreal anti VEGF injection

Neovascularization: panretinal photocoagulation

Tractional retinal detachment: surgery

PATIENTAccidental finding of young child

Take a picture and white pupil

WHITE PUPIL

Retinoblastoma:

Most common primary intraocular malignancy of

childhood

WHITE PUPIL

Malignant transformation of primitive retinal cells before final differentiation

Seldom seen after 3 years

Heritable or non-heritable

Gene RB1, 13q14

WHITE PUPIL

Retinopathy of prematurity (ROP):

WHITE PUPIL

ROPPremature infants, low birth

weight and high oxygen consumptionTreatment: anti VEGF, laser

MESSAGES

Think carefully

Eye may not be only Ophthalmic problems

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