?
Yanoff and Duker. Papil edema. 2016 In: Ophthalmology. Mosby Inc.
--- Content provided by FirstRanker.com ---
?
Khurana AK. Optic atrophy 2014 In: Comprehensive Ophthalmology. CBS Publishers
--- Content provided by FirstRanker.com ---
?Weerasinghe, D., & Lueck, C.J. (2016). Mimics and chameleons of optic neuritis. Practical
neurology;16(2):96-110.
--- Content provided by FirstRanker.com ---
?
CME: Optic Neuritis: Diagnosis, Treatment, and Prognosis.
--- Content provided by FirstRanker.com ---
https://www.medscape.org/viewarticle/571660_2?
Kahloun R et al. Infectious optic neuropathies: a clinical update. Eye and Brain 2015;7:59-81
--- Content provided by FirstRanker.com ---
?
Creel D. Visual y Evoked Potentials. 2012 Mar 1. In: Kolb H, Fernandez E, Nelson R, editors. Webvision:
--- Content provided by FirstRanker.com ---
The Organization of the Retina and Visual System [Internet]. Salt Lake City (UT): University of UtahHealth Sciences Center; 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK107218/
?
--- Content provided by FirstRanker.com ---
Pastora-Salvador N et al. Foster Kennedy syndrome: papil edema in one eye with optic atrophy in the
other eye. CMAJ 2011;183(18):2135
--- Content provided by FirstRanker.com ---
?Reynolds SA. Pinpointing Papil edema. Optometric Management 2015:82-4
https://www.optometricmanagement.com/issues/2015/september-2015/clinical-posterior
--- Content provided by FirstRanker.com ---
?
Schiffmann J et al. Evaluation and treatment of papil edema in pregnancy. Comprehensive ophthalmology
--- Content provided by FirstRanker.com ---
update 2006;7(4):187-202?
Toosy AT. Optic Neuritis. Lancet Neurol. 2014 Jan;13(1):83-99
--- Content provided by FirstRanker.com ---
2
Learning Objectives
--- Content provided by FirstRanker.com ---
? At the end of the class, students shall be able to
? Define and classify optic neuritis.
? Understand the aetiology and principles of
--- Content provided by FirstRanker.com ---
management of optic neuritis.? Understand the stages and importance of
papilloedema.
--- Content provided by FirstRanker.com ---
? Differentiate between various types of optic atrophy.
3
--- Content provided by FirstRanker.com ---
Normal optic disc4
--- Content provided by FirstRanker.com ---
Question? The disc in question is
of a 60 year old myope
--- Content provided by FirstRanker.com ---
who is instil ing timolol
eye drops since the past
--- Content provided by FirstRanker.com ---
5 years.? Is this a normal optic
--- Content provided by FirstRanker.com ---
disc?5
Optic Neuritis
--- Content provided by FirstRanker.com ---
Definition: Inflammation of the optic nerve,
impairing nerve conduction.
Secondary to demyelination, infection or
--- Content provided by FirstRanker.com ---
autoimmune pathology.
6
--- Content provided by FirstRanker.com ---
Classification
A. Papillitis
B. Retrobulbar neuritis
--- Content provided by FirstRanker.com ---
? Acute
? Chronic (toxic
amblyopia)
--- Content provided by FirstRanker.com ---
C. Neuroretinitis
D. Perineuritis
7
--- Content provided by FirstRanker.com ---
Aetiology
? Idiopathic
? Demyelinating disorders
--- Content provided by FirstRanker.com ---
? Multiple Sclerosis
? Presenting feature in 25% patients
? 70% cases occur in established disease
--- Content provided by FirstRanker.com ---
? Recurs in same/ opposite eye in 25% patients? Uhthoff"s phenomenon: impairment of vision more
with increased body temperature
--- Content provided by FirstRanker.com ---
? Pulfrich phenomenon: altered perception of movingobjects
8
--- Content provided by FirstRanker.com ---
Aetiology? Neuromyelitis optica (of Devic): acute, bilateral optic
neuritis in young patient with paraplegia
--- Content provided by FirstRanker.com ---
? Post-viral: mumps, measles, chicken pox, whooping
cough
--- Content provided by FirstRanker.com ---
? Metabolic/Nutritional deficiency:B1, B6, B12, B2, Folic acid deficiency
Thyroid dysfunction, diabetes
? Hereditary optic neuritis (Leber's disease)
--- Content provided by FirstRanker.com ---
9Aetiology
? Toxic amblyopia:
--- Content provided by FirstRanker.com ---
Chloroquine, EthambutolTobacco, Ethyl alcohol, methyl alcohol
Lead, Arsenic.
? Ischaemic: Giant cel arteritis, Takayasu's disease,
--- Content provided by FirstRanker.com ---
PAN, SLE? Granulomatous inflammation:
Sarcoidosis, tuberculosis, syphilis
--- Content provided by FirstRanker.com ---
10Symptoms
? Idiopathic/demyelinating : 20-40 years of age
? Viral: children
--- Content provided by FirstRanker.com ---
? Uniocular sudden/rapid diminution of vision? Visual loss, usually maximum by end of second week,
improves by 1-4 weeks
--- Content provided by FirstRanker.com ---
? Discomfort/pain behind eyeball especially when movedsuperiorly
11
--- Content provided by FirstRanker.com ---
Signs
? Visual Acuity: Usually 6/60 or less
? Local tenderness
--- Content provided by FirstRanker.com ---
? Pupil ary reaction: Sluggish, ill-sustained or RAPD? Impaired coloured vision: hue, brightness
? Impaired contrast sensitivity
? Delayed dark adaptation
? Visual Field: central, centrocaecal or paracentral
--- Content provided by FirstRanker.com ---
scotoma, more pronounced for coloured fields
12
--- Content provided by FirstRanker.com ---
Ophthalmoscopic findings
? Optic neuritis: MC in children,
--- Content provided by FirstRanker.com ---
engorged, oedematous optic discwith obliteration of optic cup,
small haemorrhages on disc
--- Content provided by FirstRanker.com ---
? Retrobulbar neuritis: MC in
adults
--- Content provided by FirstRanker.com ---
? Neuroretinitis:Optic neuritis+ macular star
13
--- Content provided by FirstRanker.com ---
Differential diagnosis? Papilloedema
? Pseudopapillitis
High hypermetropia,
--- Content provided by FirstRanker.com ---
Myelinated nerve fibres,Optic nerve head drusen
(blurred margin, disc not significantly
elevated, no vascular changes, stationary)
--- Content provided by FirstRanker.com ---
14Investigations
--- Content provided by FirstRanker.com ---
? MRI: demyelinatinglesions, SOL
? VEP: reduced
--- Content provided by FirstRanker.com ---
amplitude and delayed
transmission time
--- Content provided by FirstRanker.com ---
(P100 latencyincreased)
Right optic neuritis
--- Content provided by FirstRanker.com ---
15
16
--- Content provided by FirstRanker.com ---
Advanced case of optic neuritis
17
--- Content provided by FirstRanker.com ---
Course and prognosis? Recovery takes 4-6 weeks
? 90% recover normal VA, but colour vision
--- Content provided by FirstRanker.com ---
defects may persist? No correlation between initial visual loss
and final visual outcome
--- Content provided by FirstRanker.com ---
? 10% secondary or post-neuritic optic
atrophy
--- Content provided by FirstRanker.com ---
? Better outcome in young, unilateral cases18
Treatment
--- Content provided by FirstRanker.com ---
? Of cause e.g. anti-infective therapy? Intravenous methyl prednisolone 20
mg/kg/day(250 mg QID) for 3 consecutive days
followed by oral prednisolone 1-1.5 mg/kg
--- Content provided by FirstRanker.com ---
? Dexamethasone 200 mg OD pulse for 3-5 days
is a cheaper alternative
--- Content provided by FirstRanker.com ---
? Supportive therapy19
Papil oedema
--- Content provided by FirstRanker.com ---
? Definition: Bilateral, non-inflammatory
passive swelling of optic disc due to raised
Intracranial pressure.
--- Content provided by FirstRanker.com ---
? Does not develop if optic nerve is atrophic
20
--- Content provided by FirstRanker.com ---
Foster-Kennedy syndrome : contralateral
papil oedema with ipsilateral pressure atrophy of
--- Content provided by FirstRanker.com ---
optic nerve
Due to - frontal lobe tumour, olfactory meningioma
21
--- Content provided by FirstRanker.com ---
D/D: Causes of 'disc oedema'
? Papillitis, neuroretinitis
? Anterior Ischemic Optic Neuropathy
--- Content provided by FirstRanker.com ---
? Optic Nerve glioma, meningioma? Central Retinal Venous Occlusion
22
Aetio-Pathogenesis
--- Content provided by FirstRanker.com ---
? Elevated Intracranial pressure due to any cause
? Prelaminar Optic Nerve is affected by changes in tissue
pressure, IOP and CSF pressure
--- Content provided by FirstRanker.com ---
? Increased CSF pressure increases tissue pressure
hampering axoplasmic flow
--- Content provided by FirstRanker.com ---
? This further increases pressure on pre-laminar capillariesand small veins causing vasodilatation and tortuosity
? Venous drainage compromise further increases
--- Content provided by FirstRanker.com ---
congestion
23
--- Content provided by FirstRanker.com ---
General Symptoms? Headache, made worse by coughing or
straining
--- Content provided by FirstRanker.com ---
? Vomiting
? Focal neurological deficit with/without
changes in level of consciousness
--- Content provided by FirstRanker.com ---
24
Ocular symptoms
? VA may be normal until late stages
--- Content provided by FirstRanker.com ---
? Amaurosis fugax in some? In 25% patients, visual symptoms occur
only in severe, advanced papilloedema
--- Content provided by FirstRanker.com ---
25Signs
? Pupillary reactions are normal until
--- Content provided by FirstRanker.com ---
secondary atrophy sets in
? Early:
--- Content provided by FirstRanker.com ---
? Blurring of nasal>superior>inferior margins ofdisc
? Disc hyperemia and dilated capil aries
--- Content provided by FirstRanker.com ---
? Spontaneous venous pulsation absent? Splinter haemorrhages at/just off disc margin
? Normal optic cup preserved
26
--- Content provided by FirstRanker.com ---
27
Established papilloedema
--- Content provided by FirstRanker.com ---
? Margins indistinct and cup
obliterated
--- Content provided by FirstRanker.com ---
? Surface elevated upto morethan +3 D with direct
ophthalmoscope
--- Content provided by FirstRanker.com ---
? Flame-shaped haemorrhages,
cotton-wool spots
--- Content provided by FirstRanker.com ---
? Venous engorgement andperipapillary oedema
? Paton's Lines-radial lines
--- Content provided by FirstRanker.com ---
cascading from optic disc
? Macular star
--- Content provided by FirstRanker.com ---
28With progression
--- Content provided by FirstRanker.com ---
? Chronic papilloedema? Central cup remains
obliterated
--- Content provided by FirstRanker.com ---
? Haemorrhagic and exudative
components resolve gradually
--- Content provided by FirstRanker.com ---
? 'Champagne cork' appearance29
? Atrophic papilloedema
--- Content provided by FirstRanker.com ---
? Retinal vessels attenuated
with perivascular sheathing
--- Content provided by FirstRanker.com ---
? Dirty white colour due toreactive gliosis
? Leads to secondary optic
--- Content provided by FirstRanker.com ---
atrophy
30
--- Content provided by FirstRanker.com ---
Visual fields
? Early-no changes
? Established stage- enlarged blind spot
--- Content provided by FirstRanker.com ---
? Chronic- peripheral constriction of fieldwith nerve fibre bundle defects
? Finally- total loss of visual field
--- Content provided by FirstRanker.com ---
31
Fundus photo, FFA , OCT
--- Content provided by FirstRanker.com ---
32Papil oedema
Optic neuritis
--- Content provided by FirstRanker.com ---
HistoryHeadache, vomiting
Rapid DV preceded by
--- Content provided by FirstRanker.com ---
fever/respiratory infection
Laterality
--- Content provided by FirstRanker.com ---
usually bilateralusually unilateral
VA
--- Content provided by FirstRanker.com ---
normal till late stage
severely reduced <6/60
--- Content provided by FirstRanker.com ---
Pain/tenderness of eyeballabsent
may be present
--- Content provided by FirstRanker.com ---
Pupil reaction
normal
--- Content provided by FirstRanker.com ---
RAPD (Marcus-Gunn's pupil)Disc swelling
>+3 D in established
--- Content provided by FirstRanker.com ---
+2D to +3D
Haemorrhage, exudates
--- Content provided by FirstRanker.com ---
More, in establishedrelatively less
Visual fields
--- Content provided by FirstRanker.com ---
Enlarged blind spot,
Central or centrocaecal scotoma
--- Content provided by FirstRanker.com ---
later gradualconstriction
Colour vision
--- Content provided by FirstRanker.com ---
No effect
Affected
--- Content provided by FirstRanker.com ---
CT/MRISOL
Demyelinating disorder
--- Content provided by FirstRanker.com ---
Recovery of vision
May not be complete Usually complete after adequat
--- Content provided by FirstRanker.com ---
33 eeven after treatment
treatment
--- Content provided by FirstRanker.com ---
Treatment
? Treat Cause
? Acetazolamide 250 mg 4 times a day
--- Content provided by FirstRanker.com ---
? Surgical decompression of optic nerve topreserve vision
34
--- Content provided by FirstRanker.com ---
Optic Atrophy
? Definition: Degeneration of optic nerve
--- Content provided by FirstRanker.com ---
fibres with loss of their myelin sheaths
characterised by pallor of the optic disc
due to loss of vascularity owing to
obliteration of disc capillaries
--- Content provided by FirstRanker.com ---
35
Classification-Aetiological
--- Content provided by FirstRanker.com ---
Primary Optic Atrophy? No local disturbance,
associated with CNS
--- Content provided by FirstRanker.com ---
disease or no discoverable
cause
--- Content provided by FirstRanker.com ---
? Commonest cause ?Multiple Sclerosis
? Leber's optic atrophy
--- Content provided by FirstRanker.com ---
? Nerve compression:Tumour, hydrocephalus
? Injury to retrobulbar optic
nerve
--- Content provided by FirstRanker.com ---
36
Cavernous type of Primary Optic
--- Content provided by FirstRanker.com ---
Atrophy
? Deep excavated
--- Content provided by FirstRanker.com ---
cup withundermined
edges
--- Content provided by FirstRanker.com ---
? Glaucomatous
optic atrophy
--- Content provided by FirstRanker.com ---
37Aetiological classification
? Secondary optic atrophy:
--- Content provided by FirstRanker.com ---
preceded by swelling of optic disc-
papilledema, optic neuritis, neuroretinitis
? Consecutive optic atrophy:
--- Content provided by FirstRanker.com ---
follows extensive disease of the retina -
Retinitis pigmentosa
Long-standing retinal detachment
--- Content provided by FirstRanker.com ---
38
Anatomical classification
? Ascending: Lesion in retina, terminates at
--- Content provided by FirstRanker.com ---
lateral geniculate body ?
? Eg: RP, CRAO
? Descending: Disease involving optic
--- Content provided by FirstRanker.com ---
nerve fibres anterior to LGB, terminates at
optic disc ?
? Eg: chiasmal compression
--- Content provided by FirstRanker.com ---
39
--- Content provided by FirstRanker.com ---
Symptoms? Gradual/rapid loss of central/peripheral
vision
--- Content provided by FirstRanker.com ---
? Impairment of colour vision
40
--- Content provided by FirstRanker.com ---
Signs
? Visual Acuity impaired in proportion to
--- Content provided by FirstRanker.com ---
death of optic nerve fibres? RAPD in unilateral Optic Atrophy
Ultimately pupil dilated and immobile
--- Content provided by FirstRanker.com ---
41Primary OA ophthalmoscopy
? Pale disc, classically
--- Content provided by FirstRanker.com ---
paper white in colour
? Margins sharply defined
? Minimal atrophic
--- Content provided by FirstRanker.com ---
cupping
? Blood vessels
--- Content provided by FirstRanker.com ---
attenuated with markedreduction of small blood
vessels on ONH to <6
--- Content provided by FirstRanker.com ---
42
Secondary OA ophthalmoscopy
--- Content provided by FirstRanker.com ---
? Pale disc with dirty-grey
colour, blurred margins
--- Content provided by FirstRanker.com ---
? Physiological cup is full,lamina cribrosa obscured
? Narrowing of blood
--- Content provided by FirstRanker.com ---
vessels with sheathing
? Gliosis over disc surface
--- Content provided by FirstRanker.com ---
extending towardsperipapillary retina
43
--- Content provided by FirstRanker.com ---
Primary OA
Secondary OA
--- Content provided by FirstRanker.com ---
Appearancechalky white
dirty grey
--- Content provided by FirstRanker.com ---
Margins
sharply defined
--- Content provided by FirstRanker.com ---
blurredCup
deep
--- Content provided by FirstRanker.com ---
obliterated
Laminar dots
--- Content provided by FirstRanker.com ---
visiblenot visible
Glial proliferation
--- Content provided by FirstRanker.com ---
absent
marked
--- Content provided by FirstRanker.com ---
Vesselsno sheathing
sheathing
--- Content provided by FirstRanker.com ---
Previous disc oedema
absent
--- Content provided by FirstRanker.com ---
present44
--- Content provided by FirstRanker.com ---
Consecutive optic atrophy? Yellowish-waxy pallor of the disc
? Margins less sharply defined
? Marked narrowing, even obliteration of
--- Content provided by FirstRanker.com ---
retinal blood vessels
45
--- Content provided by FirstRanker.com ---
46Investigations
? Visual field: In partial OA, central vision is
--- Content provided by FirstRanker.com ---
depressed with concentric contraction ofthe visual field
? FFA of Optic nerve head
? VEP especially in children
--- Content provided by FirstRanker.com ---
? Neurological evaluation47
Hereditary optic atrophy
--- Content provided by FirstRanker.com ---
? Autosomal recessive/dominant
? LHON: Leber's hereditary OA
48
--- Content provided by FirstRanker.com ---
Treatment
? Treat the cause
--- Content provided by FirstRanker.com ---
? Gene therapy isemerging
? Community based
--- Content provided by FirstRanker.com ---
rehabilitation in
bilateral cases as
--- Content provided by FirstRanker.com ---
prognosis is poorLow-vision aids
49
--- Content provided by FirstRanker.com ---
Question
? The adjoining
--- Content provided by FirstRanker.com ---
photograph belongsto a 12 year old boy
who has difficulty in
--- Content provided by FirstRanker.com ---
seeing at night.
? Can you identify the
--- Content provided by FirstRanker.com ---
disc abnormality inthe photograph?
? What condition does
--- Content provided by FirstRanker.com ---
he suffer from?
50
--- Content provided by FirstRanker.com ---
Thank you
51
--- Content provided by FirstRanker.com ---