Download MBBS Ophthalmology PPT 16 Optic Nerve Lecture Notes

Optic Neuritis, Papil edema and Optic Atrophy

Department of Ophthalmology

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Acknowledgement

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Yanoff and Duker. Papil edema. 2016 In: Ophthalmology. Mosby Inc.

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Khurana AK. Optic atrophy 2014 In: Comprehensive Ophthalmology. CBS Publishers

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Weerasinghe, D., & Lueck, C.J. (2016). Mimics and chameleons of optic neuritis. Practical

neurology;16(2):96-110.

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CME: Optic Neuritis: Diagnosis, Treatment, and Prognosis.

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https://www.medscape.org/viewarticle/571660_2

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Kahloun R et al. Infectious optic neuropathies: a clinical update. Eye and Brain 2015;7:59-81

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Creel D. Visual y Evoked Potentials. 2012 Mar 1. In: Kolb H, Fernandez E, Nelson R, editors. Webvision:

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The Organization of the Retina and Visual System [Internet]. Salt Lake City (UT): University of Utah

Health Sciences Center; 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK107218/

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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

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Reynolds SA. Pinpointing Papil edema. Optometric Management 2015:82-4

https://www.optometricmanagement.com/issues/2015/september-2015/clinical-posterior

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Schiffmann J et al. Evaluation and treatment of papil edema in pregnancy. Comprehensive ophthalmology

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update 2006;7(4):187-202

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Toosy AT. Optic Neuritis. Lancet Neurol. 2014 Jan;13(1):83-99

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Learning Objectives

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? At the end of the class, students shall be able to
? Define and classify optic neuritis.
? Understand the aetiology and principles of

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management of optic neuritis.

? Understand the stages and importance of

papilloedema.

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? Differentiate between various types of optic atrophy.

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Normal optic disc

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Question

? The disc in question is

of a 60 year old myope

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who is instil ing timolol

eye drops since the past

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5 years.


? Is this a normal optic

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disc?

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Optic Neuritis

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Definition: Inflammation of the optic nerve,

impairing nerve conduction.
Secondary to demyelination, infection or

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autoimmune pathology.

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Classification

A. Papillitis
B. Retrobulbar neuritis

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? Acute
? Chronic (toxic

amblyopia)

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C. Neuroretinitis
D. Perineuritis

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Aetiology

? Idiopathic
? Demyelinating disorders

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? Multiple Sclerosis

? Presenting feature in 25% patients
? 70% cases occur in established disease

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? Recurs in same/ opposite eye in 25% patients
? Uhthoff"s phenomenon: impairment of vision more

with increased body temperature

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? Pulfrich phenomenon: altered perception of moving

objects

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Aetiology

? Neuromyelitis optica (of Devic): acute, bilateral optic

neuritis in young patient with paraplegia

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? Post-viral: mumps, measles, chicken pox, whooping

cough

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? Metabolic/Nutritional deficiency:
B1, B6, B12, B2, Folic acid deficiency
Thyroid dysfunction, diabetes
? Hereditary optic neuritis (Leber's disease)

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Aetiology

? Toxic amblyopia:

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Chloroquine, Ethambutol
Tobacco, Ethyl alcohol, methyl alcohol
Lead, Arsenic.

? Ischaemic: Giant cel arteritis, Takayasu's disease,

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PAN, SLE

? Granulomatous inflammation:
Sarcoidosis, tuberculosis, syphilis

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Symptoms

? Idiopathic/demyelinating : 20-40 years of age
? Viral: children

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? Uniocular sudden/rapid diminution of vision
? Visual loss, usually maximum by end of second week,

improves by 1-4 weeks

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? Discomfort/pain behind eyeball especially when moved

superiorly

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Signs

? Visual Acuity: Usually 6/60 or less
? Local tenderness

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? 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

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scotoma, more pronounced for coloured fields

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Ophthalmoscopic findings

? Optic neuritis: MC in children,

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engorged, oedematous optic disc

with obliteration of optic cup,

small haemorrhages on disc

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? Retrobulbar neuritis: MC in

adults

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? Neuroretinitis:
Optic neuritis+ macular star

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Differential diagnosis

? Papilloedema
? Pseudopapillitis
High hypermetropia,

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Myelinated nerve fibres,
Optic nerve head drusen
(blurred margin, disc not significantly
elevated, no vascular changes, stationary)

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Investigations

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? MRI: demyelinating

lesions, SOL

? VEP: reduced

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amplitude and delayed

transmission time

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(P100 latency

increased)

Right optic neuritis

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Advanced case of optic neuritis

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Course and prognosis

? Recovery takes 4-6 weeks
? 90% recover normal VA, but colour vision

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defects may persist

? No correlation between initial visual loss

and final visual outcome

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? 10% secondary or post-neuritic optic

atrophy

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? Better outcome in young, unilateral cases

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Treatment

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? 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

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? Dexamethasone 200 mg OD pulse for 3-5 days

is a cheaper alternative

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? Supportive therapy

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Papil oedema

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? Definition: Bilateral, non-inflammatory

passive swelling of optic disc due to raised
Intracranial pressure.

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? Does not develop if optic nerve is atrophic

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Foster-Kennedy syndrome : contralateral

papil oedema with ipsilateral pressure atrophy of

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optic nerve
Due to - frontal lobe tumour, olfactory meningioma

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D/D: Causes of 'disc oedema'

? Papillitis, neuroretinitis
? Anterior Ischemic Optic Neuropathy

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? Optic Nerve glioma, meningioma
? Central Retinal Venous Occlusion

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Aetio-Pathogenesis

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? Elevated Intracranial pressure due to any cause
? Prelaminar Optic Nerve is affected by changes in tissue

pressure, IOP and CSF pressure

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? Increased CSF pressure increases tissue pressure

hampering axoplasmic flow

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? This further increases pressure on pre-laminar capillaries

and small veins causing vasodilatation and tortuosity

? Venous drainage compromise further increases

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congestion

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General Symptoms

? Headache, made worse by coughing or

straining

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? Vomiting
? Focal neurological deficit with/without

changes in level of consciousness

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Ocular symptoms

? VA may be normal until late stages

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? Amaurosis fugax in some
? In 25% patients, visual symptoms occur

only in severe, advanced papilloedema

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Signs

? Pupillary reactions are normal until

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secondary atrophy sets in

? Early:

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? Blurring of nasal>superior>inferior margins of

disc

? Disc hyperemia and dilated capil aries

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? Spontaneous venous pulsation absent
? Splinter haemorrhages at/just off disc margin
? Normal optic cup preserved

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Established papilloedema

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? Margins indistinct and cup

obliterated

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? Surface elevated upto more

than +3 D with direct

ophthalmoscope

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? Flame-shaped haemorrhages,

cotton-wool spots

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? Venous engorgement and

peripapillary oedema

? Paton's Lines-radial lines

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cascading from optic disc

? Macular star

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With progression

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? Chronic papilloedema

? Central cup remains

obliterated

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? Haemorrhagic and exudative

components resolve gradually

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? 'Champagne cork' appearance

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? Atrophic papilloedema

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? Retinal vessels attenuated

with perivascular sheathing

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? Dirty white colour due to

reactive gliosis

? Leads to secondary optic

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atrophy

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Visual fields

? Early-no changes
? Established stage- enlarged blind spot

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? Chronic- peripheral constriction of field

with nerve fibre bundle defects

? Finally- total loss of visual field

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Fundus photo, FFA , OCT

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Papil oedema

Optic neuritis

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History

Headache, vomiting

Rapid DV preceded by

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fever/respiratory infection

Laterality

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usually bilateral

usually unilateral

VA

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normal till late stage

severely reduced <6/60

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Pain/tenderness of eyeball

absent

may be present

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Pupil reaction

normal

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RAPD (Marcus-Gunn's pupil)

Disc swelling

>+3 D in established

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+2D to +3D

Haemorrhage, exudates

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More, in established

relatively less

Visual fields

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Enlarged blind spot,

Central or centrocaecal scotoma

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later gradual

constriction

Colour vision

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No effect

Affected

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CT/MRI

SOL

Demyelinating disorder

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Recovery of vision

May not be complete Usually complete after adequat

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even after treatment

treatment

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Treatment

? Treat Cause
? Acetazolamide 250 mg 4 times a day

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? Surgical decompression of optic nerve to

preserve vision

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Optic Atrophy

? Definition: Degeneration of optic nerve

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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

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Classification-Aetiological

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Primary Optic Atrophy

? No local disturbance,

associated with CNS

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disease or no discoverable

cause

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? Commonest cause ?

Multiple Sclerosis

? Leber's optic atrophy

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? Nerve compression:
Tumour, hydrocephalus
? Injury to retrobulbar optic

nerve

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Cavernous type of Primary Optic

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Atrophy

? Deep excavated

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cup with

undermined

edges

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? Glaucomatous

optic atrophy

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Aetiological classification

? Secondary optic atrophy:

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preceded by swelling of optic disc-
papilledema, optic neuritis, neuroretinitis

? Consecutive optic atrophy:

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follows extensive disease of the retina -
Retinitis pigmentosa

Long-standing retinal detachment

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Anatomical classification

? Ascending: Lesion in retina, terminates at

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lateral geniculate body ?

? Eg: RP, CRAO
? Descending: Disease involving optic

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nerve fibres anterior to LGB, terminates at
optic disc ?

? Eg: chiasmal compression

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Symptoms

? Gradual/rapid loss of central/peripheral

vision

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? Impairment of colour vision

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Signs

? Visual Acuity impaired in proportion to

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death of optic nerve fibres

? RAPD in unilateral Optic Atrophy
Ultimately pupil dilated and immobile

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Primary OA ophthalmoscopy

? Pale disc, classically

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paper white in colour

? Margins sharply defined
? Minimal atrophic

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cupping

? Blood vessels

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attenuated with marked

reduction of small blood

vessels on ONH to <6

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Secondary OA ophthalmoscopy

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? Pale disc with dirty-grey

colour, blurred margins

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? Physiological cup is full,

lamina cribrosa obscured

? Narrowing of blood

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vessels with sheathing

? Gliosis over disc surface

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extending towards

peripapillary retina

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Primary OA

Secondary OA

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Appearance

chalky white

dirty grey

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Margins

sharply defined

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blurred

Cup

deep

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obliterated

Laminar dots

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visible

not visible

Glial proliferation

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absent

marked

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Vessels

no sheathing

sheathing

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Previous disc oedema

absent

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present

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Consecutive optic atrophy

? Yellowish-waxy pallor of the disc
? Margins less sharply defined
? Marked narrowing, even obliteration of

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retinal blood vessels

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Investigations

? Visual field: In partial OA, central vision is

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depressed with concentric contraction of
the visual field

? FFA of Optic nerve head
? VEP especially in children

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? Neurological evaluation

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Hereditary optic atrophy

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? Autosomal recessive/dominant
? LHON: Leber's hereditary OA

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Treatment

? Treat the cause

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? Gene therapy is

emerging

? Community based

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rehabilitation in

bilateral cases as

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prognosis is poor

Low-vision aids

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Question

? The adjoining

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photograph belongs

to a 12 year old boy

who has difficulty in

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seeing at night.

? Can you identify the

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disc abnormality in

the photograph?

? What condition does

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he suffer from?

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Thank you

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