Download - Common Visual Disorders
NERVOUS II
COMMON EYE DISORDERS
อ.พ.ญ.ลนิดา หรรษภญิโญ
อ. พ.ญ. เจนจติ ชูวุฒยากร
ภาควชิาจกัษุวทิยา คณะแพทยศาสตร ์มหาวทิยาลยัเชยีงใหม่
1. Understand basic pathology of
the neural eye disorders
2. Explained basic symptoms
3. Primary management or
suggestion
LEARNING OBJECTIVES
1. Understand basic pathology of
the neural eye disorders
2. Explained basic symptoms
3. Primary management or
suggestion
LEARNING OBJECTIVES
Optic disc edema
Pupillary abnormalities
Eye with systemic disease
VISUAL FUNCTIONS: VISUAL ACUITY
VISUAL FUNCTIONS: COLOR VISION
Ishihara plate Farnsworth D-15
Farnsworth-Munsell 100
VISUAL FUNCTIONS: CONTRAST SENSITIVITY
VISUAL FUNCTIONS: CONTRAST SENSITIVITY
SPECIAL TESTS
Visual field
Electrophysiology: VEP (visual evoked
potential), ERG (electro retinogram)
Imaging study: CT, MRI, angiography
VISUAL PATHWAY
AND
VISUAL FIELD
VISUAL PATHWAY
Optic nerve
Optic chiasm
Optic tract
Lateral geniculate body (LGB)
Anterior visual pathway
VISUAL PATHWAY
Optic radiation
Visual cortex (Occipital Lobe)
Posterior visual pathway
VISUAL FIELD
VISUAL FIELD
NORMAL VISUAL FIELD
Extension :
60 degree nasal & above
70 degree below
90 degree temporal
OPTIC NERVE LESION
CHIASMAL LESION
Bitemporal hemianopia
CHIASMAL LESION
OPTIC TRACT LESION
Contralateral
Homonymous field defects
Incongruous hemianopia
RETROGENICULATE LESION
Contralateral
Homonymous field defects
More posterior...
more congruous
OPTIC RADIATION LESION
Contralateral
Quadrantanopia
Temporal
Lobe Lesion
Parietal
Lobe Lesion
OCCIPITAL LOBE LESION
Contralateral
Complete
Homonymous hemianopia
OCCIPITAL LOBE LESION
Contralateral
Complete
Homonymous hemianopia
CONCLUSIONS
Prechiasmal lesion:
monocular field defect
Chiasmal lesion:
bitemporal field defect
Postchiasmal lesion:
homonymous field defect
OPTIC DISC EDEMA
CAUSES
Increased intracranial pressure: Papilledema
Inflammation:
Optic neuritis (papillitis) Ischemia:
Anterior ischemic optic neuropathy(AION)
Compression: Orbital tumors
CAUSES
Increased intracranial pressure: Papilledema
Inflammation:
Optic neuritis (papillitis)Ischemia:
Anterior ischemic optic neuropathy(AION)
Compression: Orbital tumors
Normal
discSwollen
disc
Headache
Vomiting
Transient visual loss
Double vision(diplopia)
Optic disc edema
Hyperemia and dilatation of surface capillaries
Edema of surrounding retina
CN VI palsies
Normal vision(acute)
SYMPTOMS AND SIGNS
SYMPTOMS AND SIGNS
UNCAL HERNIATION:CN VI PALSY
STAGING
Acute papilledema:
normal visual function
Chronic Papilledema:
loss of visual function
CAUSES
Increased intracranial pressure: Papilledema
Inflammation:
Optic neuritis (papillitis)Ischemia:
Anterior ischemic optic neuropathy(AION)
Compression: Orbital tumors
OPTIC NEURITIS
Acute/subacute visual loss
Retrobulbar pain / worse on eye
movement
15-45 y, women predominately
RAPD
Color deficit
OPTIC NEURITIS
OPTIC NEURITIS
2/3 of patients is retrobulbar (normal optic
disc) ,1/3 is papillitis (disc edema)
Most cases recover vision gradually
OPTIC NEURITIS
demyelination*(MS)
systemic infection
adjacent infection
vaccination
OPTIC NEURITIS
Oral prednisolone: placebo, increase rate of
recurrent
IV methylprednisolone followed by oral
prednisolone:faster recovery, but final VA at
6 months did not different from placebo.
ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)
An infarction of the optic nerve head caused
by inadequate perfusion by the posterior
ciliary artery
Onset of visual loss is sudden and usually
painless
ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)
Arteritic type
Non arteritic type
ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)
Non arteritic type
COMPRESSIVE OPTIC NEUROPATHY
PUPILLARY PATHWAY
PUPILLARY PATHWAY
Parasympathetic pathway Sympathetic pathway
ABNORMAL PUPILLARY RESPONSE
Relative Afferent Pupillary Defect
(RAPD)
Anisocoria
ABNORMAL PUPILLARY RESPONSE
Relative Afferent Pupillary Defect (RAPD)
Marcus Gunn pupil
Defect in direct light reflex but
preserve concentual light reflex
ABNORMAL PUPILLARY RESPONSE
Relative Afferent Pupillary Defect (RAPD)
ABNORMAL PUPILLARY RESPONSE
RAPD positive
Unilateral anterior visual pathway
Bilateral anterior visual pathway (asym.)
RAPD negative
Bilateral anterior visual pathway (sym.)
Posterior visual pathway
Relative Afferent Pupillary Defect (RAPD)
http://www.ohiolionseyeresearch.com/eye-center/glossary/anisocoria/
Anisocoria
4 mm 3 mm
Anisocoria
Anisocoria greater in dim light
4 mm 3 mm 5 mm 3 mm
Anisocoria
Anisocoria greater in dim light
4 mm 3 mm 5 mm 3 mm
Anisocoria
Anisocoria greater in dim light
4 mm 3 mm 5 mm 3 mm
4 mm 3 mm
Anisocoria
Anisocoria greater in dim light
4 mm 3 mm 5 mm 3 mm
4 mm 3 mm 4 mm 2 mm
Anisocoria
Anisocoria greater in dim light
4 mm 3 mm 5 mm 3 mm
Anisocoria greater in bright light
4 mm 3 mm 4 mm 2 mm
Anisocoria
physiologic anisocoria
large pupil affected
- oculomotor nerve palsy with pupil involvement
- tonic pupil - pharmacologic - traumatic iris damage
small pupil affected
- Horner’s syndrome
- posterior synechiae - pharmacologic
Anisocoria
ptosis (levator palpebral m)
ocular movement limitation (SR, IR, MR, IO)
pupil dilatation with sluggish react to light
Oculomotor nerve palsy
http://bombayoculoplastics.com/nerve%20palsies.htm
congenital
acquired
- pupil sparing: Ischemia (DM, HT, dyslipidemia..)
- pupil involvement: compression (aneurysm, tumor)
Oculomotor nerve palsy
deficiency of oculosympathetic activity
1. miosis
2. ptosis (mild-moderate)
3. anhidosis
Horner’s syndrome
http://www.pediatricsconsultant360.com/content/horner-syndrome
Second-order neuron(Preganglionic)
First-order neuron(Central)
Third-order neuron(Postganglionic)
diagnose & localize lesion: - associated signs and symptoms
Horner’s syndrome
Clinical Applications
Painless Visual Loss
Central retinal vein occlusion
Central retinal artery occlusion
Ischemic optic neuropathy
Cerebral stroke
Painful Visual Loss
Optic neuritis
Glaucoma
Infection: conjunctivitis, corneal ulcer etc.
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
Central Retinal Arterial Occlusion:
Predisposing factors:
Atherosclerosis
DM, HT, Hyperlipidemia,
Aging, smoking
Cardiac emboli
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
Central retinal arterial occlusion
Branch retinal arterial
occlusion
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
Treatment
Ocular massage
Cabogen (95% oxygen, 5% cabon
dioxide)
Decreased intraocular pressure
Medication
tapping
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
Central Retinal Vein Occlusion
Venous compression and thrombosis
Predisposing factors:
Aging, DM, HT, Hyperlipidemia
Hypercoagulative states,
myeloproliferative disorders
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
Branch retinal vein occlusion
Central retinal vein occlusion
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
Treatment
Observation
Neovascularization, macular edema
Laser photocoagulation
Intravitreal anti vascular endothelial
growth factor (anti-VEGF)
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
ตามัวฉับพลัน (ACUTE VISUAL LOSS)
Optic neuritis:
จอตาผิดปกติ (Retinopathy)
จุดภาพชัดผิดปกติ (Maculopathy)
ต้อกระจก (Cataract)
ต้อหิน (Glaucoma)
สายตาผิดปกติ (Refractive error)
CHRONIC VISUAL LOSS
Keratitis
Cataract
Retinal abnormalities: retinoblastoma, retinal detachment
Vitreous abnormalities: vitreous hemorrhage
Retinopathy of prematurity
WHITE PUPIL (LEUKOCORIA)
PATIENT
History of cataract surgery
Acute blurred vision: 1 day
Old age: 56 years
Red eye
Pain
ACUTE PAINFUL VISUAL LOSS
ACUTE PAINFUL VISUAL LOSS
Endophthalmitis: Endogenous
Post surgery
Trauma
ACUTE PAINFUL VISUAL LOSS
Treatment
Antibiotics: systemic, intravitreal injection
Surgery
PATIENT
Distorted vision
AMSLER GRID TEST
CHRONIC PROGRESSIVE VISUAL LOSS
Epiretinal membrane:
CHRONIC PROGRESSIVE VISUAL LOSS
Macular hole:
CHRONIC PROGRESSIVE VISUAL LOSS
Treatment
surgery
Hypertensive retinopathy
arteriovenous nicking
cotton wool spot
retinal hemorrhage
Chronic Progressive Visual Loss
Treatment: observe, laser
Chronic Progressive Visual Loss
CHRONIC PROGRESSIVE VISUAL LOSS
Diabetic retinopathy
CHRONIC PROGRESSIVE VISUAL LOSS
Treatment
Controlled blood sugar
Macular edema: laser, intravitreal anti VEGF injection
Neovascularization: panretinal photocoagulation
Tractional retinal detachment: surgery
PATIENTAccidental finding of young child
Take a picture and white pupil
WHITE PUPIL
Retinoblastoma:
Most common primary intraocular malignancy of
childhood
WHITE PUPIL
Malignant transformation of primitive retinal cells before final differentiation
Seldom seen after 3 years
Heritable or non-heritable
Gene RB1, 13q14
WHITE PUPIL
Retinopathy of prematurity (ROP):
WHITE PUPIL
ROPPremature infants, low birth
weight and high oxygen consumptionTreatment: anti VEGF, laser
MESSAGES
Think carefully
Eye may not be only Ophthalmic problems
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