optic neuritis
TRANSCRIPT
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Optic NeuritisOptic Neuritis
Robert H. Spector, MDRobert H. Spector, MD
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Visual PathwayVisual Pathway
Seeing
Looking
• Fixation When You are in Motion
When the Object is in Motion
When You and the Object are in Motion
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Two optic nerves = 2.4 million Two optic nerves = 2.4 million fibersfibers
Man is a Seeing Man is a Seeing AnimalAnimal
Five Five SensesSenses
SeeingSeeingHearingHearingTouchTouchSmellSmellTasteTaste
Each ear = 30,000 nerve Each ear = 30,000 nerve fibersfibers
HearinHearingg
Two ears = 60,000 nerve Two ears = 60,000 nerve fibersfibers
Seeing 2.4 Seeing 2.4 millionmillion
Hearing 60,000Hearing 60,000= = 4040::11
SeeingSeeingEach optic nerve = 1.2 million Each optic nerve = 1.2 million fibersfibers
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Cerebral HemispheresCerebral Hemispheres
CerebellumCerebellum
BrainstemBrainstem
Seeing and LookingSeeing and Looking
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Response = Image
Response = Image
Stimulus = Light
Stimulus = Light
Cerebral HemispheresCerebral Hemispheres
Visual ReflexStimulusResponse
Visual ReflexStimulusResponse
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Seeing
Eye Catches the Image
In Peripheral Vision
Looking
Moves the Eyes to Find the Image and Lock on
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SeeingSeeingGray matterGray matter
White matterWhite matter
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Gray MatterGray Matter
WhiteWhite
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Optic Nerve is White Matter Optic Nerve is White Matter
In the Eyepapilla or optic disc
In the Eyepapilla or optic disc
Behind Eye retrobulbarretro=behind
bulbar= eyeball
Behind Eye retrobulbarretro=behind
bulbar= eyeball
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Papilla or Optic DiscPapilla or Optic Disc
maculamacula
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maculamaculamaculamacula
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The Optic DiscThe Optic Disc
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Inspection of the Optic Disk
Inspection of the Optic Disk
•Size
•Color
•Cup
•Vessels
•Nerve Fiber Layer
•Size
•Color
•Cup
•Vessels
•Nerve Fiber Layer
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NerveFiberLayer(NFL)
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Normal NFL Loss of NFL
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Nerve Fiber Layer Loss: subtleNerve Fiber Layer Loss: subtle
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Visual Acuity
Visual Field
Color Vision
Afferent Pupil
“Depression of
Central Vision”
“Depression of
Central Vision”
Hallmark of Optic NeuritisHallmark of Optic Neuritis
How Do We Measure How Do We Measure Central VisionCentral Vision
How Do We Measure How Do We Measure Central VisionCentral Vision
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Visual Acuity: Ability to discriminate a target in the very center of visual field: 2-4 degreesVisual Acuity: Ability to discriminate a target in the very center of visual field: 2-4 degrees
Loss of Visual Acuity
Expressed as Ratio20/20
20/100
distance/letter size
Loss of Visual Acuity
Expressed as Ratio20/20
20/100
distance/letter size
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Visual Field: the expanse of vision looking straight ahead at a fixed target with one eyeVisual Field: the expanse of vision looking straight ahead at a fixed target with one eye
targettarget
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Visual Field “Island of Vision in a Sea of Blindness”
Visual Field “Island of Vision in a Sea of Blindness”
✈✈✈✈
♂♂
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Visual Acuity
Visual Field
Color Vision
Afferent Pupil
“Depression of
Central Vision”
“Depression of
Central Vision”
Hallmark of Optic NeuritisHallmark of Optic Neuritis
How Do We Measure How Do We Measure Central VisionCentral Vision
How Do We Measure How Do We Measure Central VisionCentral Vision
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Depressed Color PerceptionDepressed Color Perception
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Afferent Pupil Defect (APD) or Marcus Gunn Sign
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
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Visual Acuity
Visual Field
Color Vision
Afferent Pupil
“Depression of
Central Vision”
“Depression of
Central Vision”
Hallmark of Optic NeuritisHallmark of Optic Neuritis
How Do We Measure How Do We Measure Central VisionCentral Vision
How Do We Measure How Do We Measure Central VisionCentral Vision
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Causes of Optic Neuropathy
Causes of Optic Neuropathy
• MS
• Infections: Lyme, Syphilis
• Granulomatous: Sarcoid, Tuberculosis
• Vascular: stroke
• Neoplastic: cancer
• Iatrogenic: postoperative complication
• Inflammatory: systemic lupus erythematosus
• Toxic: methylalcohol
• Dietary: B12 deficiency
• Traumatic
• MS
• Infections: Lyme, Syphilis
• Granulomatous: Sarcoid, Tuberculosis
• Vascular: stroke
• Neoplastic: cancer
• Iatrogenic: postoperative complication
• Inflammatory: systemic lupus erythematosus
• Toxic: methylalcohol
• Dietary: B12 deficiency
• Traumatic
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MS is But One Cause of Optic Neuritis It is Not the Only Cause
MS is But One Cause of Optic Neuritis It is Not the Only Cause
Optic Neuritis = Inflammation of the Optic
NerveOptic Neuritis = Inflammation of the Optic
Nerve
… itis = inflammation: meningitis, appendicitis, gastritis, hepatitis
… itis = inflammation: meningitis, appendicitis, gastritis, hepatitis
Syphilis Rocky Mt. Spotted
FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Syphilis Rocky Mt. Spotted
FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Many CausesMany Causes
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• Loss of central visual field
• Loss of visual acuity
• Loss of color perception
• Afferent Pupil
• Loss of central visual field
• Loss of visual acuity
• Loss of color perception
• Afferent Pupil
retro=behindbulbar= eyeball
Two Forms of Optic Neuritis
• Papillitis
• Retrobulbar Neuritis
Two Forms of Optic Neuritis
• Papillitis
• Retrobulbar Neuritis
Optic NerveOptic Nerve
Both Forms of Optic NeuritisBoth Forms of Optic Neuritis
papillaoptic disc
papillaoptic disc retrobulbarretrobulbar
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PapillitisPapillitis Optic Disc is SwollenOptic Disc is Swollen
•Loss of central visual field
•Loss of visual acuity
•Loss of color perception
•Afferent Pupil
•Loss of central visual field
•Loss of visual acuity
•Loss of color perception
•Afferent Pupil
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Retrobulbar NeuritisRetrobulbar Neuritis Optic Disc is FlatOptic Disc is Flat
•Loss of central visual field
•Loss of visual acuity
•Loss of color perception
•Afferent Pupil
•Loss of central visual field
•Loss of visual acuity
•Loss of color perception
•Afferent Pupil
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•Accurate diagnosis
•Further Evaluation
•MRI, blood work, spinal fluid analysis
•Acute Treatment:
•Intravenous Methylprednisolone
•Intramuscular ACTHAR
• •
Long-term Treatment
•Clinically Isolated Syndrome
•Accurate diagnosis
•Further Evaluation
•MRI, blood work, spinal fluid analysis
•Acute Treatment:
•Intravenous Methylprednisolone
•Intramuscular ACTHAR
• •
Long-term Treatment
•Clinically Isolated Syndrome
Issues Regarding Optic NeuritisIssues Regarding Optic Neuritis
Syphilis Rocky Mt. Spotted
FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Syphilis Rocky Mt. Spotted
FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
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Issues Regarding Optic NeuritisIssues Regarding Optic Neuritis
•Accurate Diagnosis
•Further Evaluation
•Accurate Diagnosis
•Further Evaluation
Syphilis Rocky Mt. Spotted FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Syphilis Rocky Mt. Spotted FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
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Conditions Often Misdiagnosed as Optic Neuritis Conditions Often Misdiagnosed as Optic Neuritis
Cat Scratch Optic Neuritis
Cat Scratch Optic Neuritis
ExudatesExudates
MS -- Not the Only Cause of Optic Neuritis
MS -- Not the Only Cause of Optic Neuritis
full face tfull face t
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Pitfalls in Ordering an MRI
Pitfalls in Ordering an MRI
46-yo woman with Progressive Visual Loss in her Left eye
46-yo woman with Progressive Visual Loss in her Left eyeInterpretation: Normal MRIInterpretation: Normal MRI
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Brain MRIBrain MRI
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Exit 12Exit 12285285MRIMRI
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fat suppressionfat suppression
contrast agent contrast agentthin sections of the optic nervethin sections of the optic nerve
MRI Scan Proper Technique
For Identifying MS
MRI Scan Proper Technique
For Identifying MS
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MRI with Proper Technique MRI with Proper Technique
Retrobulbar Neuritis
Retrobulbar Neuritis
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Acute Treatment of Visual Loss from Optic
Neuritis
Acute Treatment of Visual Loss from Optic
Neuritis
• Intravenous Methylprednisolone
•ACTHAR
• Intravenous Methylprednisolone
•ACTHAR
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MaintenanceMaintenance
•Subcutaneous
• Intramuscular
• Intravenous
•Oral
•Symptomatic
•Subcutaneous
• Intramuscular
• Intravenous
•Oral
•Symptomatic
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MRI in MSMRI in MS•Initial Diagnosis
•Predictive Value
•Helps Determine Effectiveness of Therapy
•Initial Diagnosis
•Predictive Value
•Helps Determine Effectiveness of Therapy