Visual Loss Of Neuroophthalmic Interest'

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Visual Loss Of Neuro-ophthalmic Interest.

• Prof. Dr. P. Sudhakar.
• Professor And Head Of Department.
• Strabismus And Neuro-ophthalmology Clinic.
• RIOGOH Chennai.

Presentation at CME on Neuro-ophthalmic
Disorders. at Regional Institute of
Ophthalmology and Government Ophthalmic Hospital,
Chennai. September 16, 2006.
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Visual Loss Form And Function.

• Visual loss symptoms vary greatly in meaning from
  patient to patient.
• They range from blurring to complete blindness.
• May affect one or both eyes.
• Components of visual function, namely, acuity
  field color and brightness appreciation may be
  affected jointly or separately.

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Profound Loss Of Vision.

• Common causes.
• Vascular.
• Anterior ischemic optic neuropathy (AION).
• Ischemic central retinal vein Occlusion (CRVO).
• Central retinal artery occlusion (CRAO).
• Inflammatory.
• Optic neuritis.
• Infiltrative, compressive, inherited,
  nutritional.
• Optic neuropathy.

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Segmental Loss Of Vision.

• Vascular.
• Branch retinal artery occlusion (BRAO).
• Branch retinal vein occlusion (BRVO).
• Anterior ischemic optic neuropathy (AION).

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Loss Of Central Vision.

• Common causes.
• Vascular.
• Cilio-retinal artery occlusion.
• Inflammatory.
• Optic neuritis.
• Infiltrative, compressive, inherited or
  nutritional.
• Optic neuropathy.

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Transient Loss Of Vision.

• Vascular
• Thrombo-embolic
• Carotid artery disease, cardiac,
  Vertebro-basillar
• Carotid occlusion
• slow flow retinopathy
• Vasculitis
• GCA, SLE, PAN, RA

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Transient Loss Of Vision.

• Neurological
• Papilloedema
• Migraine
• ocular, classic

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Macular Vs Optic Nerve Causes.
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Decreased Vision With Macular Changes.

• Maculopathies.
• Solar Maculopathy, ARMD, Cystoid Macular Oedema,
  CSR.
• Cone-Rod dystrophy.
• Macular hole.
• Epiretinal membrane.
• Central vision loss, color vision and field loss.
• RAPD only in severe macular disease.

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Decreased Vision With Retinal Changes.

• CRAO.
• cause mostly embolus carotid, cardiac or great
  vessels.
• also in young patients carotid dissection or
  vasospasm.
• Ischemic CRVO.
• visual loss over days to weeks.
• RAPD present.

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Decreased Vision With Normal Disc.

• Anterior chiasmal syndrome.
• Central visual field loss in one eye with
  superior temporal defect in the opposite eye.
• Mid chiasmal lesions.
• relative or absolute Bi-temporal Hemianopia
  without loss of acuity.
• Normal Central Acuity. No RAPD.

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Decreased Vision With Normal Disc.

• Posterior chiasmal lesions.
• Homonymous field loss.
• in Optic Tract, Temporal, Parietal and Occipital
  lobe lesions.
• Visual Radiations.
• Anterior lesions - Incongruous defects.
• Posterior lesions - Congruous defects.
• Hemianopic Scotomata respecting vertical
  meridian.
• Normal Central Acuity / No RAPD.

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Decreased Vision With Disc Edema.

• Papilloedema.
• Optic neuropathy of increased ICP.
• Visual acuity and color vision are usually normal
  unless the macula is involved.
• Enlargement of blind spot.
• Transient visual obscurations.
• Normal Central Acuity. No RAPD.

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Decreased Vision With Disc Edema.

• Pseudotumor Cerebri Idiopathic ICH.
• Obese, third decade and in females.
• Associated with endocrine or metabolic
  dysfunction, pregnancy, Hypervitaminosis A.
• Tetracycline, oral contraceptives or steroid
  withdrawal.
• Normal Central Acuity. No RAPD.

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Decreased Vision With Disc Edema.

• AION.
• painless monocular profound visual loss.
• develops over hours to days.
• with arcuate / altitudinal field loss.
• Sometimes central cecocentral scotoma and
  generalized depression.
• Types
• AAION Less common, gt 70 yrs, female.
• NAION More common. In lt60 years.
• Decreased Central Acuity. Positive RAPD.

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Decreased Vision With Disc Edema.

• AAION.
• inflammatory and thrombotic occlusion of Short
  Posterior Ciliary arteries.
• systemic symptoms of Temporal Arthritis.
• Elevated ESR, C- reactive proteins and platelet
  count.
• Confirm diagnosis by temporal artery biopsy.
• Fellow eye often involved in days to weeks.
• Decreased Central Acuity. Positive RAPD.

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Decreased Vision With Disc Edema.

• NAION.
• A compromise of disc microcirculation as in HT,
  DM.
• Risk factors Smoking, SLE, hyperlipidaemia,
  migraine.
• Visual loss and disc pallor are less severe than
  AAION.
• Optic atrophy occurs by 10 weeks and ensues in
  fellow eye. Pseudo Faster- Kennedy Syndrome.
• Differentiated from Optic neuritis by patients
  age (gt 50 yrs), painless EOM and segmental disc
  edema.
• FFA Delayed optic disc filling in NAION while
  normal in optic neuritis.
• Decreased Central Acuity. Positive RAPD.

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Decreased Vision With Disc Edema.

• Papillitis.
• Post-viral and specific neuritis than in
  idiopathic demyelinating neuritis.
• Bilateral in children.
• Macular star may occur neuro-retinits /
  distinguishing from the demyelinating etiology.
• Chronic Papilloedema.
• Orbital compressive lesions.
• Infiltrative optic neuropathy.
• Decreased Central Acuity. Positive RAPD.

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Decreased Vision With Normal Disc.

• Retro-bulbar neuritis.
• Young females. Pain on ocular movement precedes
  visual loss.
• Sub acute monocular central vision loss / central
  scotoma or central diffuse loss developing over
  days to weeks.
• Dyschromatopsia for red present.
• Isolated or associated with viral, demyelinating,
  vasculitic or granulomatous processes.
• Typical idiopathic RB neuritis recovers in 3
  months time.
• Decreased Central Acuity Positive RAPD.

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Decreased Vision With Normal Disc.

• Retro-bulbar neuritis- Other conditions.
• Graves Ophthalmopathy.
• Infiltrative Optic Neuropathy.
• Perioptic Meningeal Carcinamatosis.
• Posterior ION due to systemic hypotension,
  anaemia, GI bleed, vasculitis.
• Acute Compressive Optic Neuropathy.
• LHON.
• Decreased Central Acuity Positive RAPD.

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Decreased Vision With Normal Disc.

• Traumatic optic neuropathy.
• Trauma to the head, orbit or globe.
• Direct trauma results in avulsion of optic nerve
  itself or laceration by bone fragments.
• Indirect trauma minor frontal injury shears the
  nerve and its blood supply at its
  intra-canalicular tethering.
• Indirect trauma is most common. Vision loss is
  immediate and severe.
• Normal disc at onset but optic atrophy sets in
  4-8 weeks.
• Decreased Central Acuity. Positive RAPD.

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Decreased Vision With Abnormal Disc Appearance.

• Optic nerve sheath Meningioma.
• Intra-canalicular or intra-orbital portions.
• Females of 40-50 years.
• Frisen Triad 1. Painless, progressive monocular
  vision loss.
• 2. Optic atrophy.
• 3. Opto-ciliary shunt vessels.
• MRI diffuse tubular enlargement of the optic
  nerve Sheath thickening and enhancement sparing
  of optic nerve - Tram track sign.
• CT scan Calcification of nerve sheath Adjacent
  bony hyperostosis.
• Decreased Central Acuity. Positive RAPD.

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Decreased Vision With Abnormal Disc Appearance.

• Optic Nerve Glioma.
• Children in first or second decade no sex
  predilection.
• Signs Proptosis, severe vision loss, optic
  atrophy and strabismus.
• Neuroradiology is diagnostic.
• Fusiform or globular enlargement of the optic
  nerve.
• Thickening of both nerve and sheath Kinking.
• or buckling of the optic nerve.
• Cystic spaces in the nerve regions of low
  intensity.
• No calcification or hyperostosis.
• Decreased Central Acuity. Positive RAPD.

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Decreased Vision With Abnormal Disc Appearance.

• LHON.
• Typically affects males 10-30yrs.
• Acute, severe, painless monocular visual loss and
  central or cecocentral field impairment.
• The classic fundus
• PseudoedemaHyperemiaDisc elevationPeri-papillar
  y thickening.
• Peripapillary telangectasia.
• Tortuosity of medium sized retinal arterioles.
• FFA no leakage or staining of the disc.
• The second eye involved within weeks or months.
• Decreased Central Acuity. Positive RAPD.

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Decreased Vision With Normal Disc.

• Amblyopia.
• Unexplained monocular visual loss.
• Consider Previously existing amblyopia.
• Causes anisometropia, astigmatism, or small
  angle heterotropia.
• Crowding phenomenon Improvement of visual acuity
  with the testing of isolated letters rather than
  entire lines.
• Decreased Central Acuity. No RAPD.

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Decreased Vision With Normal Disc.

• Toxic/Nutritional Optic Neuropathy.
• Gradually progressive, bilaterally symmetrical,
• Painless central visual loss.
• Central or cecocentral scotoma.
• Methanol toxicity rapid onset of severe
  bilateral visual loss with prominent disc edema.
• Diagnosis requires a careful history for possible
  medication, toxic exposure, drug abuse or dietary
  deficiency.
• Decreased Central Acuity. No RAPD.

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Decreased Vision With Abnormal Disc Appearance.

• Dominant optic atrophy.
• Most common Hereditary Optic neuropathy in first
  decade.
• Insidious bilateral visual loss with color vision
  defects often detected in school screening.
• There is central or ceco-central field loss.
• Temporal Optic atrophy or diffusely pale disc.
• A wedge shaped temporal excavation is highly
  suggestive of DOA, but its absence does not rule
  out DOA.
• Decreased Central Acuity. No RAPD.

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Decreased Vision With Abnormal Disc Appearance.

• Optic Chiasmal Glioma.
• Bilateral visual loss with Bi-temporal field
  loss.
• Disc maybe atrophic / normal / edematous.
• See-saw nystagmus If brain stem pathways
  involved.
• Obstructive Hydrocephalus with Papilloedema in
  large tumours.
• Decreased Central Acuity. No RAPD.

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• T h a n k y o u.