Download OPTIC NERVE DISEASE

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2013 WTD OPHTH ®
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SUDDEN PAINLESS
LOSS OF VISION
WALTER T. DELPERO MD FRCSC
ASSISTANT PROFESSOR UNIVERSITY OF
OTTAWA
REVISED 2015
ALL RIGHTS RESERVED
Objectives:
 Describe
the most common and
important causes of painless loss of
vision.
 Link common types of visual loss to
systemic disease.
 Describe appropriate
investigations/screening when such
a condition is identified.
2015WTD OPHTH ®
What will be discussed:
 Vision
anatomy review.
 Decreased vision due to mechanical
blockage.
 Retinal problems: arterial or vein
occlusion, retinal detachment or
inflammation, macular
degeneration.
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What will be discussed:
 Optic
nerve: Optic neuritis,
Anterior Ischemic Optic
Neuropathy (ischemic and nonischemic)
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Ocular anatomy
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Vision Pathway
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Central vision/retinal anatomy
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Anatomy of the pupillary reflex
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Something blocking the light from
reaching the retina
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VITREOUS HEMORRHAGE
Mechanical blockage of light.
Contraction of vitreous pulls at
vessels on or over the retina.
May be associated with a retinal
tear.
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RED REFLEX : will identify
an opacity along the visual axis
Normal
Something blocking the light from shining back.
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Retinal Neovascularization:
caused by ischemia, can lead to
hemorrhage,blocking light to retina
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Pre retinal Hb: boat shaped Hb
Note you cannot see fovea.
Red reflex will be reduced.
OPTIC NERVE
FOVEA
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RED REFLEX:
Vitreous Hb
Normal
Reduced on left
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OTHER CAUSES OF A
VITREOUS HEMORRHAGE
Neovascualization from retinal
ischemia.
Diabetes
Sickle cell
Carotid artery disease
Old Central Retinal Vein
Occlusion (CRVO)
CHECK THE RED REFLEX
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DIABETIC RETINOPATHY
Normal
Background DR
Laser treatment
Proliferative DR
Note the new blood vessel
growth
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PROLIFERATIVE DIABETIC
RENINOPATHY
ENDSTAGE
Fibrotic Retina
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Treatment options:
Panretinal Photocoagulation
Laser scars 1600 – 2000
Reduce production of
Vascular endothelial
growth factor.
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Ocular anatomy
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RETINAL DYSFUNCTION
Central retinal artery occlusion.
Commonly secondary to embolic
phenomena.
Curtain coming down =
Amaurosis Fugax
Fundoscopy shows pale fundus
with cherry red spot.
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Central Retinal Artery
Occlusion (CRAO)
This is an embolic event,
source typically carotid or cardiac
CHERRY RED SPOT
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CENTRAL RETINAL ARTERY
OCCLUSION
Cherry red spot
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Branch Retinal Artery
Occlusion (BRAO)
Embolus
Retinal Edema
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RETINAL DYSFUNCTION
Central retinal vein occlusion
shows diffuse hemorrhage and
cotton wool spots.
Blood and Thunder.
R/O underlying disease, blood
dyscrasia, HT, glaucoma.
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Central Retinal Vein
Occlusion (CRVO)
Blood and Thunder
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Central Retinal Vein Occlusion (CRVO)
Cotton wool spots (CWS)
Retinal Hemorrhages
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RETINAL DYSFUNCTION
Branch retinal vein occlusion
shows Hb and CWS localized.
Edema may extend into the
foveal area and decrease vision.
Blockage occurs at arterial venous
crossings, most commonly
associated with longstanding HT.
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Branch Retinal Vein Occlusion (BRVO)
Most common in Hypertensive
patients.
CWS
(Cotton wool spots)
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RETINAL DYSFUNCTION
Cytomegalovirus Retinitis (CMV)
Newborns
Immunocompromised: Iatrogenic,
HIV-AIDS
Visualized in posterior pole.
“Pizza Pie” appearance.
Early detection and treatment can
preserve vision.
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CMV Retinitis: loss of actual
retina.
Think immunosuppression
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CMV RETINITIS
Loss of all retinal details
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Types of age related macular
degeneration (AMD)
 Dry
AMD
TYPICALLY OVER AGE 65, FAMILY
HISTORY A MAJOR FACTOR.
PROGRESSION IS SLOW UNLESS
COVERSION TO WET.
 Wet
AMD
DRY IS MANAGED WITH VITS
WET WITH ANTI-VEGF INJ.
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SUBRETINAL HEMORRHAGE
Wet age relate macular degeneration (AMD)
SUBRETINAL HEMORRHAGE
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WET Age Related Macular
Degeneration (AMD)
 Elderly
person (>65)
 Central painless loss of VA
 Treatment now available with
anti-VEGF (Avastin/Lucentis)
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RETINAL DETACHMENT
Retinal detachment: separation of
the photoreceptors from the
underlying RPE. Symptoms:
Flashing lights, floaters, shadow
in visual field.
Can be determined with
examination of red reflex and
direct fundoscopy.
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Retinal
Detachment
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Horseshoe tear with RD
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RETINAL DETACHMENT
Retina separating from Retinal Pigment Epithelium
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RETINAL DETACHMENT
REPAIR
Scleral Buckle
Buckle acts to reduce traction
by the vitreous on the retina
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OPTIC NERVE DISEASE
Metabolically and neurologically
one of the most active pathways
in the body.
Any compromise of nutrition,
compression, or local
inflammation will decrease
function.
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CENTRAL RETINAL ARTERY
Retina
Optic
Nerve
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Relative Afferent Pupillary Defect (RAPD)
Checked by a swinging
flashlight test.
Pupillary reflex anatomy: both
pupils appear the same size
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Relative afferent pupillary defect (RAPD)
N.B : pupils appear equal
in ambiant light unless the
defect is brought out by the
swinging flashlight test.
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OPTIC NERVE DISEASE
OPTIC NEURITIS: viral or
autoimmune. Affects younger
age group.
Symptoms: Central scotoma, loss
of colour vision, +/- pain, symps
worsen with increased body
temperature
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OPTIC NERVE DISEASE
Vision worsens over 1-2 weeks
with slow improvement in 4 to 12
weeks.
Vast majority improve to 20/40 or
better.
Signs: Relative afferent pupillary
defect. Systemic findings of
neurological impairment.
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RETROBULBAR NEURITIS
Decreased vision with a normal red
reflex and fundus exam
Normal Fundus
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Colour Desaturation Test
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OPTIC NERVE DISEASE
Treatment is controversial: No
oral prednisone. Use I.V.
methylprednisolone for first 3
days. Currently will give 1200mg
of prednisone daily x 3D.
Tincture of time is the mainstay
of treatment.
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OPTIC NERVE DISEASE
Associated with MS development
in 75% F and 35% M over 15
years.
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OPTIC NERVE DISEASE
 Arteritic
and Non-Arteritic
Anterior ischemic optic
neuropathy. (NAOIN and AION)
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OPTIC NERVE DISEASE
TEMPORAL ARTERITIS: Giant
cell arteritis (GCA), Vasculitic
process affecting people over the
age of 55. Compromises blood
supply to optic nerve.
Systemically can affect the heart,
brain kidneys etc.
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ANTERIOR ISCHEMIC OPTIC NEUROPATHY
Optic nerve edema
note loss of optic
nerve edge details
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Optic nerve edema
Flame Hemorrhage
Cotton wool spot
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OPTIC NERVE DISEASE
Systemic symps: malaise, weight
loss, muscle weakness or
tenderness, jaw claudication.
Common in arteritic-AION
Poor circulation, DM, nocturnal
hypotension in Non-arteritic
AION.
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OPTIC NERVE DISEASE
 “Disc
at Risk”
Crowded disc
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OPTIC NERVE DISEASE
RAPD may also be present with
disc swelling. Lab test of choice is
an ESR and CRP. Temporal
artery biopsy is the gold
standard. (Within 2 wks)
IF SUSPICIOUS GIVE
PREDNISONE.
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CASE HISTORY
67y/o male with hypertension, and
poor compliance presents
complaining of sudden decreased
vision in the right eye.
Hint: think vascular
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CASE HISTORY
21y/o female states that over the
last 2 days her vision has
decreased in her right eye to
counting fingers vision. She has
only mild pain and denies
trauma.
Hint: Age
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CASE HISTORY
55y/o female 12hrs post coronary
artery bypass surgery complains
of being unable to see from her
left eye. There is no pain and
externally the eye appears
normal.
Hint: Vascular
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CASE HISTORY
40y/o male states he lost vision in
his right eye after seeing flashing
light and “spider webs”. He is a
–10.00 myope.
Hint: Long eye, stretched retina.
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CASE HISTORY
77y/o female is sent to you from
geriatrics. She was initially being
worked up for lethargy and
weight loss. Complained of vision
coming and going for several
days and now states she cannot
see at all from either eye.
2014 WTD OPHTH ®
CASE HISTORY
38y/o male with longstanding
insulin dependant diabetes
presents with sudden loss of
vision in his left eye. He has had
only moderate blood sugar
control as he takes his insulin
only when he feels he needs it.
2013 WTD OPHTH ®
CASE HISTORY
32y/o male with HIV-AIDS, on
antiretrovirals and a sulpha
drug, presents with painless loss
of vision in his right eye. This has
worsened over the last several
days.
Hint: retinal infection
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