Neuro-ophthalmology
Dr. Nabil Islam
MBBS, DO
Assistant surgery
CEITC, Chittagong
Optic neuritis
Optic neuritis includes inflammatory and
demyelinating disorder of the optic nerve.
Cause 3. Infectious
1. Demyelinating - Tuberculosis
disorder - Syphilis.
- Multiple sclerosis. 4. Autoimmune disorder
2. Parainfectious - Sarcoidosis.
- measles - Systeic lupus
- mumps erythromatosis.
- chicken pox 5. Toxic optic neuritis.
- whooping cough. 6. Idiopathic.
- after immunization. 7. Hereditary
Type
A. Anatomical type
1. Papllitis.
Involvement of optic disc.
2. Neuroretinitis
Involvement of optic disc and surrounding retina in
the macular area. (macular star)
3. Retrobulbar neuritis
Involvement of the optic nerve behind the eyeball.
optic nerve head normal.
Symptom
1. Marked loss of vision.
2. Pain may be present with ocular movement.
Sign
It is usually unilateral
1. Visual acuity- marked dimness of
vision.
2. Pupil- RAPD
3. Color vision- Impaired ( RED GRENN)
4. Fundus examination
a. optic disc
Margin- Blurred.
Color- Hyperemic.
Disc swelling- 3 D
b. Peripapillary oedema.
c. Venous engorgement.
d. Retinal exudate
e. Macular star ( Neuroretinitis)
Incase of retrobulbar neuritis- no
fundus abnormality.
5. Visual field- central scotoma.
Investigation
[Link] brain and orbit
a. optic nerve- Gadolinum enhancement.
b. Brain- White plaques in cerebrum,
brainstem, spinal cord and cerebelum.
2. Other investigation to exclude cause.
Treatment
1. Corticosteroid therapy.
2. Immunosupression therapy.
Papiloedema
Papilloedema may be defined as optic disc swelling
associated with raised intracranial pressure.
Occurs usually bilateraly
Pathophysiology of papilloedema
1. Compression of central retinal vein as it
crosses the subarachnoid space.
2. Blockage of axoplasmic transport
↑ ICP
↑pressure in the subarachnoid space around
optic nerve
Compression of central Blockage of axoplasmic
retinal vein transport
Swelling of optic disc
Cause of papilloedema
1. Space occupying intracranial lesions.
2. Idiopathic intracranial hypertension.
3. Obstruction of ventricular system.
4. Impairment of CSF absorption( meningitis,
subarachnoid haemorrhage or trauma)
5. Hypersecretion of CSF. ( choroidal plexus tumor).
6. Cerebral venous sinus thrombosis.
7. Cerebral oedema.
8. Severe hypertension.
Symptom
1. Headache.
2. Nausea, projectile vomiting.
3. Deterioration of consciousness.
4. Visual acuity usually normal. Later vision
decreases due to optic atrophy.
5. Transient attack of blurred vision.
6. Horizontal diplopia due to 6th nerve palsy.
Sign
It is usually bilateral
1. Visual acuity- Near normal. Decrease at late stage due to atrophy
2. Pupil- Normal
3. Color vision- Normal
4. Fundus examination
a. optic disc
Margin- Blurred.
Color- Hyperemic.
Disc swelling- 2-6 D
b. Peripapillary oedema.
c. Venous engorgement- marked.
d. Retinal haemorrhage- marked
d. Retinal exudate- Marked
5. Visual field- Enlarged blind spot.
Invetigation
1. MRI brain
- Space occupying lesion
- Ventricular obstruction.
- Optic nerve sheath diameter ( normal 5.5
mm ± 1 mm)
2. B- scan
- Optic nerve sheath diameter.
Optic neuritis Papiloedema
Laterality Usually unilateral Usually bilateral
Symptom Marked loss of vision Usually normal.
Transient attack of blurred
vision.
Pupil RAPD Normal
Color vision Impaired Normal
Fundus
Media May be hazy due to clear
posterior vitritis
Optic disc margin Blurred Blurred
Optic disc color Hyperemic Hyperemic
Optic disc oedema Less then 3D 2-6 D
Peripapillary oedema Present Present
Venous engorgement More marked present
Retinal Hge More marked present
Retinal exudate More marked Present
