papilloedema and optic atrophy

8/11/2019 Papilloedema and Optic Atrophy

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Fundoscopicexamination


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Fundoscopic Examination

Window to theblood vessels

Prerequisites-

Goodophthalmoscope

A large pupil

A still field


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Fundoscopic Examination

Diminish illumination in the room( to overcomelight reflex)

Instruct the pt to look at a distant point, which is

clearly defined( to overcome accomodation andkeeping the eye still)

Rt eye for examining rt fundus, lt eye for leftfundus


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Fundoscopic Examination First find the optic disc

Colour Edges Optic cup Nasal blurring, temporal pallor- Normal

Vessels CRA- superior and inferior branches, nasal & temporal br-four

prominent arterial trunks emanating from the disc Vns are larger and darker Arteries are lighter and narrower than vns and often have a

central reflecting line silver-wireappearance Point of crossing of arteries and vns

Haemorrhage and exudates Macula, Peripheral retina


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Optic disc

Optic cup

Vein

Arterioles

Fovea

Normal Ocular Fundus


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Fundoscopic Examination Cup to Disk Ratio

Diameter of thecupped region of theoptic nerve head

divided by thediameter of the opticnerve head.

Normal is ~0.3-0.5.

Abnormal values arehigher and areassociated with

glaucomaC/D = 0.6


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Cotton Wool Spots

Cotton wool spots resultfrom occlusion of retinalpre-capillary arteriolessupplying the nerve fibrelayer with concomitant

swelling of local nervefibre axons. Also called"soft exudates"or"nerve fibre layerinfarctions" they arewhite, fluffy lesions inthe nerve fibre layer.

Papilloedema, HTN, PAN,retinal embolism, severeanaemia


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Hard exudates

Hard exudates ( Intra-retinal lipid exudates )are yellow deposits oflipid and protein within

the retina.Accumulations of lipidsleak from surroundingcapillaries andmicroaneurysms, they

may form a circinatepattern.

Hyperlipidemia maycorrelate with thedevelopment of hardexudates.


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Papilledema- Definition

Swelling of optic disc

Arbitrarily, the term has been

reserved for the passive disc swellingassociated with raised ICP

Usually bilateral, although it may beasymmetrical


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Causes of papilledema (Raised ICP)


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Clinical Features of Papilledema

Usually bilateral but may be unilateral or asymmetric

Usually preserved visual acuity and color vision early

May have transient visual loss lasting seconds(obscurations of vision)

Visual field defects Enlarged blind spot

Generalized constriction

Glaucomatous-like defects

Eventual peripheral constriction, especially nasally

No afferent pupillary defect


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Papilledema showing blurred disc margins and dilated

tortuous vessels


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Early papilledema

Minimal disc hyperemia with capillary dilation Early opacification of nerve fiber layer (peripapillary

retina loses its superficial linear and curvilinear lightreflex and appears red without luster)

Early swelling of disc

Absence of venous pulsations Peripapillary retinal nerve fiber layer hemorrhage


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Fully developed papilledema Engorged and tortuous retinal veins May have splinter hemorrhages at or adjacent to the disc margin Disc surface grossly elevated Surface vessels become obscured by now opaque nerve fiber layer May have cotton wool spots Patons lines (circumferential retinal folds) or choroidal folds

Hemorrhage and exudates In acute cases (e.g., subarachnoid hemorrhage), subhyaloid hemorrhages

may occur that may break into vitreous (Tersons syndrome)


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Frisen Papilledema Grading SystemStage 1

Obscuration of the nasalborder of the disc

No elevation of the discborders

Disruption of the normalradial nerve fiber layer(NFL) arrangement withgrayish opacityaccentuating nerve fiberbundles

Normal temporal discmargin

Subtle grayish halo withtemporal gap

C-shaped halo with a temporal gap
http://webeye.ophth.uiowa.edu/eyeforum/cases/images/PE/Slide6.jpg


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Obscuration of allborders

Elevation of nasal

border Complete

peripapillary halo

Halo becomes circumferential


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Obscuration of allborders

Elevation of all borders Increased diameter of

the optic nerve head Obscuration of one ormore segments ofmajor blood vesselsleaving the disc

Peripapillary halo

irregular outer fringewith finger-likeextensions

Loss of major vessels as

they leave the disc (arrow)


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Elevation of entirenerve head

Obscuration of all

borders Peripapillary halo

Total obscurationon the disc of asegment of a majorblood vessel

loss of major vessels ON THE DISC
http://webeye.ophth.uiowa.edu/eyeforum/cases/images/PE/Slide9.jpghttp://webeye.ophth.uiowa.edu/eyeforum/cases/images/PE/Slide9.jpg


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Dome-shapedprotrusionsrepresenting anteriorexpansion of the opticnerve head

Peripapillary halo isnarrow and smoothlydemarcated

Total obscuration of asegment of a major

blood vessel may ormay be present Obliteration of the

optic cup

Grade IV plus partial ortotal obscuration of all vessels of the disc


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Pseudopapilledema

Optic nerve drusen

Medullated nerve fiber

Hypermetropic disc Congenital anomalous elevation


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Optic atrophy - Definition

Optic nerve shrinkage from anyprocess that produce degeneration of

axons in the ant.visual(Retinogeniculate) pathway


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CLASSIFICATION OF OPTICATROPHY

PRIMARY-

SECONDARY Post- papilloedemic optic atrophy

Post-Neuritic optic atrophy

Glaucomatous optic atrophy

Consecutive optic atrophy


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PRIMARY OPTIC ATROPHY

Optic nerve fibersdegenerate in an orderlymanner and are replacedby columns of glial cellswithout alteration in the

architecture of the opticnerve head Pale disc Chalky white(full moon

against a dark red sky) Clear margin of

disc/sharply demarcated Normal cup Well seen lamina cribrosa Normal retinal vessels


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Secondary optic atrophy

Optic nerve fibers exhibit marked degeneration, withexcessive proliferation of glial tissue

The architecture is lost, resulting in indistinct margins.The disc is grey or dirty grey , looks pale with a

greenish tinge The margins are poorly defined,

The lamina cribrosa is obscured due to proliferatingfibroglial tissue.

Hyaline bodies (corpora amylacea) or drusen may be

observed. Peripapillary sheathing of arteries as well as tortuous

veins may be observed.


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Secondary optic atrophy


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OPTIC ATROPHY

The Kestenbaum count is the numberof capillaries observed on the opticdisc.

The normal count is approximately10.

In optic atrophy, the number of thesecapillaries reduces to less than 6; in ahyperemic disc, the count is morethan 12


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papilloedema and optic atrophy

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