Visual Loss Of  Neuro-ophthalmic Interest.

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September 2006.. www.riogohchennai.ac.in. 2 / 29. Visual Loss Form And Function.. Visual loss symptoms vary greatly in meaning from patient to patient.They range from blurring to complete blindness.May affect one or both eyes.Components of visual function, namely, acuity; field; color and br

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Visual Loss Of Neuro-ophthalmic Interest.

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1. September 2006. www.riogohchennai.ac.in 1 29 Visual Loss Of Neuro-ophthalmic Interest. Prof. Dr. P. Sudhakar. Professor And Head Of Department. Strabismus And Neuro-ophthalmology Clinic. RIOGOH Chennai.

2. September 2006. www.riogohchennai.ac.in 2 / 29 Visual Loss – Form And Function. Visual loss symptoms vary greatly in meaning from patient to patient. They range from blurring to complete blindness. May affect one or both eyes. Components of visual function, namely, acuity; field; color and brightness appreciation may be affected jointly or separately.

3. September 2006. www.riogohchennai.ac.in 3 / 29 Profound Loss Of Vision. Common causes. Vascular. Anterior ischemic optic neuropathy (AION). Ischemic central retinal vein Occlusion (CRVO). Central retinal artery occlusion (CRAO). Inflammatory. Optic neuritis. Infiltrative, compressive, inherited, nutritional. Optic neuropathy.

4. September 2006. www.riogohchennai.ac.in 4 / 29 Segmental Loss Of Vision. Vascular. Branch retinal artery occlusion (BRAO). Branch retinal vein occlusion (BRVO). Anterior ischemic optic neuropathy (AION).

5. September 2006. www.riogohchennai.ac.in 5 / 29 Loss Of Central Vision. Common causes. Vascular. Cilio-retinal artery occlusion. Inflammatory. Optic neuritis. Infiltrative, compressive, inherited or nutritional. Optic neuropathy.

6. September 2006. www.riogohchennai.ac.in 6 / 29 Transient Loss Of Vision. Vascular Thrombo-embolic: Carotid artery disease, cardiac, Vertebro-basillar Carotid occlusion slow flow retinopathy Vasculitis GCA, SLE, PAN, RA

7. September 2006. www.riogohchennai.ac.in 7 / 29 Transient Loss Of Vision. Neurological Papilloedema Migraine ocular, classic

8. September 2006. www.riogohchennai.ac.in 8 / 29 Macular Vs Optic Nerve Causes.

9. September 2006. www.riogohchennai.ac.in 9 / 29 Decreased Vision With Macular Changes. Maculopathies. Solar Maculopathy, ARMD, Cystoid Macular Oedema, CSR. Cone-Rod dystrophy. Macular hole. Epiretinal membrane. Central vision loss, color vision and field loss. RAPD only in severe macular disease.

10. September 2006. www.riogohchennai.ac.in 10 / 29 Decreased Vision With Retinal Changes. CRAO. cause mostly embolus: carotid, cardiac or great vessels. also in young patients’ carotid dissection or vasospasm. Ischemic CRVO. visual loss over days to weeks. RAPD present.

11. September 2006. www.riogohchennai.ac.in 11 / 29 Decreased Vision With Normal Disc. Anterior chiasmal syndrome. Central visual field loss in one eye with superior temporal defect in the opposite eye. Mid chiasmal lesions. relative or absolute Bi-temporal Hemianopia without loss of acuity. Normal Central Acuity. No RAPD.

12. September 2006. www.riogohchennai.ac.in 12 / 29 Decreased Vision With Normal Disc. Posterior chiasmal lesions. Homonymous field loss. in Optic Tract, Temporal, Parietal and Occipital lobe lesions. Visual Radiations. Anterior lesions - Incongruous defects. Posterior lesions - Congruous defects. Hemianopic Scotomata respecting vertical meridian. Normal Central Acuity / No RAPD.

13. September 2006. www.riogohchennai.ac.in 13 / 29 Decreased Vision With Disc Edema. Papilloedema. Optic neuropathy of increased ICP. Visual acuity and color vision are usually normal unless the macula is involved. Enlargement of blind spot. Transient visual obscurations. Normal Central Acuity. No RAPD.

14. September 2006. www.riogohchennai.ac.in 14 / 29 Decreased Vision With Disc Edema. Pseudotumor Cerebri – Idiopathic ICH. Obese, third decade and in females. Associated with endocrine or metabolic dysfunction, pregnancy, Hypervitaminosis A. Tetracycline, oral contraceptives or steroid withdrawal. Normal Central Acuity. No RAPD.

15. September 2006. www.riogohchennai.ac.in 15 / 29 Decreased Vision With Disc Edema. AION. painless monocular profound visual loss. develops over hours to days. with arcuate / altitudinal field loss. Sometimes central & cecocentral scotoma and generalized depression. Types: AAION: Less common, > 70 yrs, female. NAION: More common. In <60 years. Decreased Central Acuity. Positive RAPD.

16. September 2006. www.riogohchennai.ac.in 16 / 29 Decreased Vision With Disc Edema. AAION. inflammatory and thrombotic occlusion of Short Posterior Ciliary arteries. systemic symptoms of Temporal Arthritis. Elevated ESR, C- reactive proteins and platelet count. Confirm diagnosis by temporal artery biopsy. Fellow eye often involved in days to weeks. Decreased Central Acuity. Positive RAPD.

17. September 2006. www.riogohchennai.ac.in 17 / 29 Decreased Vision With Disc Edema. NAION. A compromise of disc microcirculation as in HT, DM. Risk factors: Smoking, SLE, hyperlipidaemia, migraine. Visual loss and disc pallor are less severe than AAION. Optic atrophy occurs by 10 weeks and ensues in fellow eye. Pseudo Faster- Kennedy Syndrome. Differentiated from Optic neuritis by patient’s age (> 50 yrs), painless EOM and segmental disc edema. FFA: Delayed optic disc filling in NAION while normal in optic neuritis. Decreased Central Acuity. Positive RAPD.

18. September 2006. www.riogohchennai.ac.in 18 / 29 Decreased Vision With Disc Edema. Papillitis. Post-viral and specific neuritis than in idiopathic demyelinating neuritis. Bilateral in children. Macular star may occur – neuro-retinits / distinguishing from the demyelinating etiology. Chronic Papilloedema. Orbital compressive lesions. Infiltrative optic neuropathy. Decreased Central Acuity. Positive RAPD.

19. September 2006. www.riogohchennai.ac.in 19 / 29 Decreased Vision With Normal Disc. Retro-bulbar neuritis. Young females. Pain on ocular movement precedes visual loss. Sub acute monocular central vision loss / central scotoma or central diffuse loss developing over days to weeks. Dyschromatopsia for red present. Isolated or associated with viral, demyelinating, vasculitic or granulomatous processes. Typical idiopathic RB neuritis recovers in 3 months time. Decreased Central Acuity & Positive RAPD.

20. September 2006. www.riogohchennai.ac.in 20 / 29 Decreased Vision With Normal Disc. Retro-bulbar neuritis- Other conditions. Graves Ophthalmopathy. Infiltrative Optic Neuropathy. Perioptic Meningeal Carcinamatosis. Posterior ION due to systemic hypotension, anaemia, GI bleed, vasculitis. Acute Compressive Optic Neuropathy. LHON. Decreased Central Acuity & Positive RAPD.

21. September 2006. www.riogohchennai.ac.in 21 / 29 Decreased Vision With Normal Disc. Traumatic optic neuropathy. Trauma to the head, orbit or globe. Direct trauma results in avulsion of optic nerve itself or laceration by bone fragments. Indirect trauma: minor frontal injury shears the nerve and its blood supply at its intra-canalicular tethering. Indirect trauma is most common. Vision loss is immediate and severe. Normal disc at onset but optic atrophy sets in 4-8 weeks. Decreased Central Acuity. Positive RAPD.

22. September 2006. www.riogohchennai.ac.in 22 / 29 Decreased Vision With Abnormal Disc Appearance. Optic nerve sheath Meningioma. Intra-canalicular or intra-orbital portions. Females of 40-50 years. Frisen Triad: 1. Painless, progressive monocular vision loss. 2. Optic atrophy. 3. Opto-ciliary shunt vessels. MRI: diffuse tubular enlargement of the optic nerve; Sheath thickening and enhancement; sparing of optic nerve - Tram track sign. CT scan: Calcification of nerve sheath; Adjacent bony hyperostosis. Decreased Central Acuity. Positive RAPD.

23. September 2006. www.riogohchennai.ac.in 23 / 29 Decreased Vision With Abnormal Disc Appearance. Optic Nerve Glioma. Children in first or second decade; no sex predilection. Signs: Proptosis, severe vision loss, optic atrophy and strabismus. Neuroradiology is diagnostic. Fusiform or globular enlargement of the optic nerve. Thickening of both nerve and sheath; Kinking. or buckling of the optic nerve. Cystic spaces in the nerve – regions of low intensity. No calcification or hyperostosis. Decreased Central Acuity. Positive RAPD.

24. September 2006. www.riogohchennai.ac.in 24 / 29 Decreased Vision With Abnormal Disc Appearance. LHON. Typically affects males 10-30yrs. Acute, severe, painless monocular visual loss and central or cecocentral field impairment. The classic fundus: Pseudoedema:Hyperemia;Disc elevation;Peri-papillary thickening. Peripapillary telangectasia. Tortuosity of medium sized retinal arterioles. FFA: no leakage or staining of the disc. The second eye involved within weeks or months. Decreased Central Acuity. Positive RAPD.

25. September 2006. www.riogohchennai.ac.in 25 / 29 Decreased Vision With Normal Disc. Amblyopia. Unexplained monocular visual loss. Consider: Previously existing amblyopia. Causes: anisometropia, astigmatism, or small angle heterotropia. Crowding phenomenon: Improvement of visual acuity with the testing of isolated letters rather than entire lines. Decreased Central Acuity. No RAPD.

26. September 2006. www.riogohchennai.ac.in 26 / 29 Decreased Vision With Normal Disc. Toxic/Nutritional Optic Neuropathy. Gradually progressive, bilaterally symmetrical, Painless central visual loss. Central or cecocentral scotoma. Methanol toxicity: rapid onset of severe bilateral visual loss with prominent disc edema. Diagnosis requires a careful history for possible medication, toxic exposure, drug abuse or dietary deficiency. Decreased Central Acuity. No RAPD.

27. September 2006. www.riogohchennai.ac.in 27 / 29 Decreased Vision With Abnormal Disc Appearance. Dominant optic atrophy. Most common Hereditary Optic neuropathy in first decade. Insidious bilateral visual loss with color vision defects often detected in school screening. There is central or ceco-central field loss. Temporal Optic atrophy or diffusely pale disc. A wedge shaped temporal excavation is highly suggestive of DOA, but its absence does not rule out DOA. Decreased Central Acuity. No RAPD.

28. September 2006. www.riogohchennai.ac.in 28 / 29 Decreased Vision With Abnormal Disc Appearance. Optic Chiasmal Glioma. Bilateral visual loss with Bi-temporal field loss. Disc: maybe atrophic / normal / edematous. See-saw nystagmus: If brain stem pathways involved. Obstructive Hydrocephalus with Papilloedema: in large tumours. Decreased Central Acuity. No RAPD.

29. September 2006. www.riogohchennai.ac.in 29 / 29 T h a n k y o u.

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