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Grand Rounds Conference

Grand Rounds Conference. Janelle Fassbender , MD, PhD University of Louisville Department of Ophthalmology and Visual Sciences July 18, 2014. Subjective. CC: Neurologist requesting full exam HPI : 15 year old girl with epilepsy referred to pediatric ophthalmology by her neurologist.

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Grand Rounds Conference

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  1. Grand Rounds Conference Janelle Fassbender, MD, PhD University of Louisville Department of Ophthalmology and Visual Sciences July 18, 2014

  2. Subjective CC: Neurologist requesting full exam HPI: 15 year old girl with epilepsy referred to pediatric ophthalmology by her neurologist.

  3. History POH: Strabismus surgery 3 years prior by outside ophthalmologist PMH: epilepsy, asthma, attention deficit disorder Eye Meds: None Meds: lamotrigine, oxcarbazine, lisdexamfetamine Allergies: NKDA

  4. Objective OD OS BCVA: 20/25 20/25 Pupils: 5 to 3 mm OU, No RAPD IOP: 17 17 EOM: Full Full CVF: Superonasal Superotemporal defect defect

  5. Objective Slit Lamp Exam: External/Lids Normal OU Conjunctiva/Sclera Normal OU Cornea Clear OU Anterior Chamber Deep, quiet OU Iris Normal OU Lens Clear OU VitreousNormal OU

  6. Dilated Fundus Exam OD: OS: *Inferior camera artifact

  7. Visual Fields (24-2) OD: OS: Left superior homonymous quandrantanopia

  8. Pre-operative MRI Brain Normal brain MRI *Patient is rotated on table, yielding asymmetry between right and left lobes.

  9. Post-operative MRI Brain Anterior, inferior and lateral resection of temporal lobewith cystic hygroma and normal post-operative changes.

  10. Diagnosis • Left superior quandrantanopia secondary to right temporal lobectomy for temporal lobe epilepsy.

  11. Treatment plan • Observe

  12. Follow-up • Year 2 • Stable visual field defect

  13. The Visual Pathway • High anatomical variability in the optic radiations • Up to 15 mm anteriorly and 15 mm posteriorly (Winston, 2013).

  14. Optic Radiations • 3 Bundles (Winston, 2013): • Anterior bundle (Meyer’s Loop) – Sharp inferolateral turn to end in lower calcarine fissure • Central bundle – passes lateral and posterior to the occipital pole • Posterior bundle – direct posterior course to the upper calcarine fissure

  15. Optic radiations Patient post-op Diffusion tensor tractography – representative image (Bartroli, 2010)

  16. Temporal lobe surgery • Temporal lobe resective surgery (Georgiadis, 2013): • Broad range of surgical options: Anterior temporal lobe resection, selective amygdalohippocampectomy • Newer approaches may spare optic radiations (Winston, 2013)

  17. Visual field defects following temporal lobectomy • Visual field defects – 50-100% • Most commonly superior quadrantanopia(Piper et al, 2014) • Other noted complications (Georgiadis, 2013): • Trochlear nerve palsy – 2.6 to 19% • Transient oculomotor nerve palsy – 2.1% • Hemiparesis – 4.6%

  18. Population receptive field analysis of primary visual field cortex complements perimetry in patients with homonymous visual field defects.Papanikolaou A, et al. 2014. PNAS, 11(16):E1656-1665. • Visual cortex activity outside of scotoma expected from automated perimetry.

  19. References • Krolak-Salom P, et al. 2000. Anatomy of optic nerve radiations as assessed by static perimetry and MRI after tailored temporal lobectomy. British Journal of Ophthalmology, 84:884-889. • Piper RJ, et al. 2014. Application of diffusion tensor imaging and tractography of the optic radiation in anterior temporal lobe resection for epilepsy: A systematic review. Clinical Neurology and Neurosurgery, 124:59-65. • Fong KCS. 2003. Eye, 17:330-333. • Winston GP. 2013. Epilepsia, 54(11): 1877-1888. • Papanikolaou A, et. Al. 2014. Proc Natl Acad Sci U S A, 111(16): E1656–E1665. • Georgiadis et al. 2013. Epilepsy Research and Treatment. • Bartroli V. 2010. http://wssprojects.bmt.tue.nl/sites/bmia/SysParts/Collection.aspx?XPage=b8734eb9-59be-4ffd-8ebe-4dfe8cb40854:SetFilter:FilterField1%3d%252540ID%26FilterValue1%3d292

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