Neuro-ophthalmology

1. Neuro-ophthalmology sjtu ophthalmology 樊莹

2. Neuro-ophthalmology • an important sensory end organ • intimatedly related to the brain • cranial nerves: 50％II、III、IV、V、VI、VII • cranial nerve fiber: 38％ • intracranial diseases: 65％ • vision loss blindness die diagnosis including etiology and location

3. optic neuropathy

4. structure of retina

5. nerve fiber layer

6. sensory visual pathway

8. anatomy of the optic nerve • from optic disc to optic chiasm • length：45~50mm including：intraglobe 1 mm intraorbit 25~30 mm optic canal 5 mm intracrania 10 mm

9. histology of the optic nerve • comprised by ganglion cell axons • covered by meninges (3 layers) • lack of Schwann's cells • hard to rebuild

11. to valuate optic nerve • morphology：ophthalmoscope ultrasonic X-ray CT MRI • function：vision acuity visual field pupil test VEP+ERG dark adaption colour perception

12. visual field testing steady fixation measure the comdined function of the retina “peripheral vision” <30°central visual field >30°peripheral visual field

13. kinetic perimetry

14. static perimetry

15. electrophysiologic testing • electrooculogram EOG • electroretinogram ERG • visual evoked potential VEP

17. pupil

18. light reflex normal abnormal

19. optic neuropathy • inflammatory： optic neuritis • vascular： anterior ischemic optic neuropathy (AION) • neoplastic infiltration： glioma, leukaemia, lymphoma, meningeal carcinomatosis • others： optic atrophy、papilledema

20. Optic neuritis duo to a variety of causes the most common is demyelination else:immune-mediated direct infections granulomatous optic nueropathy contiguous inflammatory disease

21. demyelinative optic neuritis • clinical features: chiefly in women(3:1) chiefly in white associated with multiple sclerosis subacute(2~7days) color vision and contrast sensitivity impaired pain(in eye 90%)(by eye movement 50%) abmormal in pupil testing change in VEP a central scotoma in most cases brain MRI (necesssary) • including: papillitis retrobulbar neuritis

22. Papillitis • in 35% cases • hyperemia of the optic disk and large veins(early signs) • edema (nearly more than 3D) (common) • blurring of the disk margins (common) • filling of the physiologic cup (common) • retinal exudates and edema (uncommon) • hemorrhage (uncommon) • vitreous cells (uncommon)

23. Papillitis Fundus

24. FFA Papillitis

25. Papillitis CT Visual field

26. Retrobulbar neuritis • vision loss • no obvious changes in the optic disk (at earlier stage) • secondary optic atrophy

27. demyelinative optic neuritis differential diagnosis: • compressive optic neuropathy • anterior ischemic optic neuropathy • autoimmune optic neuropathy • toxic amblyopia • Leber's hereditary optic neuropathy • vitamin B12 deficiency • papilledema

28. demyelinative optic neuritis treatment: • steroid therapy can accelerate recovery of vision can not influence the ultimate visual outcome may increase the risk of recurrency • intravenous steroid therapy useful for multiple sclerosis

29. anterior ischemic optic neuropathy (AION) due to infarction of the retrolaminar optic nerve from occlusion or decreased perfusion of the short posterior ciliary arteries

30. vessels of the optic nerve

31. AION causes: • arteriosclerosis • diabetes • hypertension • hyperlipidemia • intracranial stroke • vasculitis,migraine,inherited prothrombotic states(in younger patients) • reduced cup,optic nerve head drusen,increased intraocular pressure

32. AION clinical features: • in the sixth or seventh decade • vision loss without pain • generally abrupt,progressive • altitudinal vision field defects() • FFA:decreased perfusion segmented the nonarteritic form diffuse the arteritic form disk leakage the late phase

33. AION

34. AION

35. AION treatment: No treatment has been shown to provide long-term benefit. Low-dose aspirin may reduce the risk of involvement of the fellow eye. identify the arteritic AION (high-dose systemic steroids)

36. Papilloedema noninflammatory congestion due to raised intracranial pressure causes • intracranial mass • abscesses • subdural hematoma • arteriovenous malformation • subarachnoid hemorrhage • meningitis or encephalitis • acquired hydrocephalitis • else

37. Papilledema increased intracranial pressure axonal transpot is blocked edema

38. Papilledema clinical features: • normal vision in most cases for early papilledema • 1~2days to occur and 1 week to develop fully • severe vision loss for late papilledema

39. Papilledema the early stage

40. papilledema the middle stage

41. papilledema the late stage

42. papilledema • FFA

43. papilledema differential diagnosis: • burid drusen of the optic nerve • small hyperopic disks • AION • myelinated nerve fibers

44. papilledema treatment: deal with the underlying cause

45. Optic atrophy • primary optic atrophy • secondary optic atrophy

47. Optic atrophy

48. Optic atrophy treatment: to the underlying cause

49. optic nerve tumor • glioma of optic nerve • meningioma of optic nerve

50. Glioma of optic nerve