Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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. 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 Objective BCVA: Pupils: IOP: EOM: CVF: OD OS 20/25 20/25 5 to 3 mm OU, No RAPD 17 17 Full Full Superonasal Superotemporal defect defect Objective Slit Lamp Exam: External/Lids Conjunctiva/Sclera Cornea Anterior Chamber Iris Lens Vitreous Normal OU Normal OU Clear OU Deep, quiet OU Normal OU Clear OU Normal OU Dilated Fundus Exam OD: *Inferior camera artifact OS: Visual Fields (24-2) OS: OD: Left superior homonymous quandrantanopia Pre-operative MRI Brain Normal brain MRI *Patient is rotated on table, yielding asymmetry between right and left lobes. Post-operative MRI Brain Anterior, inferior and lateral resection of temporal lobe with cystic hygroma and normal post-operative changes. Diagnosis Left superior quandrantanopia secondary to right temporal lobectomy for temporal lobe epilepsy. Treatment plan Observe Follow-up Year 2 Stable visual field defect The Visual Pathway High anatomical variability in the optic radiations Up to 15 mm anteriorly and 15 mm posteriorly (Winston, 2013). 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 Optic radiations Diffusion tensor tractography – Patient post-op representative image (Bartroli, 2010) 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) 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% 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. 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-8ebe4dfe8cb40854:SetFilter:FilterField1%3d%252540ID%26FilterValue1%3d292