Grand rounds conference
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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.

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Grand rounds conference

Grand Rounds Conference

Janelle Fassbender, MD, PhD

University of Louisville

Department of Ophthalmology and Visual Sciences

July 18, 2014


Subjective

Subjective

CC: Neurologist requesting full exam

HPI: 15 year old girl with epilepsy referred to pediatric ophthalmology by her neurologist.


History

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

Objective

OD OS

BCVA: 20/25 20/25

Pupils: 5 to 3 mm OU, No RAPD

IOP: 1717

EOM: FullFull

CVF:Superonasal Superotemporal defect defect


Objective1

Objective

Slit Lamp Exam:

External/LidsNormal OU

Conjunctiva/ScleraNormal OU

CorneaClear OU

Anterior ChamberDeep, quiet OU

IrisNormal OU

LensClear OU

VitreousNormal OU


Dilated fundus exam

Dilated Fundus Exam

OD:

OS:

*Inferior camera artifact


Visual fields 24 2

Visual Fields (24-2)

OD:

OS:

Left superior homonymous quandrantanopia


Pre operative mri brain

Pre-operative MRI Brain

Normal brain MRI

*Patient is rotated on table, yielding asymmetry between right and left lobes.


Post operative mri brain

Post-operative MRI Brain

Anterior, inferior and lateral resection of temporal lobewith cystic hygroma and normal post-operative changes.


Diagnosis

Diagnosis

  • Left superior quandrantanopia secondary to right temporal lobectomy for temporal lobe epilepsy.


Treatment plan

Treatment plan

  • Observe


Follow up

Follow-up

  • Year 2

    • Stable visual field defect


The visual pathway

The Visual Pathway

  • High anatomical variability in the optic radiations

    • Up to 15 mm anteriorly and 15 mm posteriorly (Winston, 2013).


Optic radiations

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 radiations1

Optic radiations

Patient post-op

Diffusion tensor tractography – representative image (Bartroli, 2010)


Temporal lobe surgery

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 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%


Grand rounds conference

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

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-8ebe-4dfe8cb40854:SetFilter:FilterField1%3d%252540ID%26FilterValue1%3d292


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