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Optical Coherence Tomography and Investigation of Optic Neuropathies. Dina Mohammed Abdulmannan Umm Al- Qura University. Optic Neuropathies. Demyelinating Compressive Ischemic Toxic/Nutritional Traumatic Hereditary Inflammatory/Infectious. Optic Neuropathies and OCT.

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optical coherence tomography and investigation of optic neuropathies

Optical Coherence Tomography and Investigation of Optic Neuropathies

Dina Mohammed Abdulmannan

Umm Al-Qura University

optic neuropathies
Optic Neuropathies
  • Demyelinating
  • Compressive
  • Ischemic
  • Toxic/Nutritional
  • Traumatic
  • Hereditary
  • Inflammatory/Infectious
optic neuropathies and oct
Optic Neuropathies and OCT
  • To monitor loss of retinal nerve fiber layer (RNFL) thickness
  • RNFL thickness is a reflection of axonal integrity in response to injury
case 1 anterior ischemic optic neuropathy
Case 1: Anterior Ischemic Optic Neuropathy
  • 70-year old gentleman
  • “Blurred vision” in the right eye upon awakening
  • No Giant Cell Arteritis Symptoms
  • Vascular risk factors: Diabetes, Hypertension, and Dyslipidemia
case 1 aion
Case 1: AION
  • Visual Acuity:20/40 OD

20/25 OS

  • Pupils:RAPD OD
  • IOP:19 mm Hg in both eyes
  • Fundus:Optic disc edema in the right eye. Absent physiological cup in the left eye
case 1 aion clinical course
Case 1: AION Clinical Course
  • Vision worsened in the right eye after a week - Count fingers
  • No Symptoms of GCA
  • ESR = 6 mm per hour
fundus photos
OS

OD

Fundus Photos

Optic disc

edema (OD)

case 1 aion and vf
OS

OD

Case 1: AION and VF
  • MD -25.80 dB
  • Greater loss in superior field
  • MD -3.60 dB
fast rnfl thickness 3 4
Fast RNFL Thickness (3.4)

3.4 mm

1.92 seconds

case 1 rnfl findings
Case 1: RNFL findings

Mean RNFL = 52 µ

  • RNFL thinning in the right eye relative to the left eye
  • Greatest loss in inferior region correlating with superior VF loss

Mean RNFL = 82 µ

case 1 anterior ischemic optic neuropathy1
Case 1: Anterior Ischemic Optic Neuropathy
  • OCT done 6 months following ischemic onset
  • What is timeline for axon loss to occur?
  • Does timeline differ across other optic neuropathies?
case 2 recurrent optic neuritis
Case 2: Recurrent Optic Neuritis
  • 20-year old young woman
  • Developed “blurring” in the right eye
  • Pain with extraocular movements
case 2 recurrent optic neuritis1
Case 2: Recurrent Optic Neuritis

Past Medical History

  • Bilateral optic neuritis in 1993
    • treated with IV steroids
    • Cranial MRI scan normal
    • CSF analysis normal
    • No antecedent illness
    • Residual vision loss 20/40 OD and color vision deficit
slide14
Case 2: Recurrent Optic Neuritis
  • Recurrent optic neuritis in the right eye in 2000
    • Repeat MRI scan normal
    • Vision recovered to baseline
  • Recurrence of optic neuritis in right eye in spring 2003
case 2 recurrent optic neuritis2
Case 2: Recurrent Optic Neuritis
  • Present Visual Acuity:

20/40 OD 20/20 OS

  • Pupils: Right RAPD
  • Fundus: Bilateral optic atrophy (temporal pallor)
case 2 visual fields
OD

OS

Case 2: Visual Fields
  • MD -3.81 dB
  • MD -10.39 dB
  • Central loss greater in OD
rnfl thickness
OD

OS

RNFL Thickness
  • Bilateral RNFL thinning
  • worse in OD
case 1 recurrent optic neuritis
Case 1: Recurrent Optic Neuritis
  • Few reserve axons remaining in OD
    • Following 3 bouts of optic neuritis
  • What extent of axonal loss will predict a permanent deficit in vision?
case 3 optic neuritis
Case 3: Optic Neuritis
  • 32-year old woman
  • Diagnosed with MS in 1992
  • Reported 6 recurrent bouts of optic neuritis affecting both eyes
  • Denied active optic neuritits at the time of examination
case 3 optic neuritis1
Case 3: Optic Neuritis
  • Visual Acuity: 20/25 OU
  • Pupils: left RAPD
  • Color Vision: 9/16 Ishihara plates in the right eye, and 6/16 plates in the left eye
  • Fundus: Bilateral optic atrophy
case 3 optic neuritis2
OD

OS

Case 3: Optic Neuritis

MD -4.31 dB

MD -3.03 dB

case 3 optic neuritis3
OS

OD

Case 3: Optic Neuritis
  • Residual central field depression OU
  • Greater in left eye
rnfl thickness1
ODRNFL Thickness

OS

  • RNFL thinning in the left eye relative to the right
rnfl vs visual field loss
RNFL vs Visual Field Loss
  • How well does the pattern of RNFL loss reflect or correlate with visual field loss in these patients?
case 4 compressive optic neuropathy
Case 4: Compressive Optic Neuropathy
  • 18 year old male
  • Developed headache and vision loss in both eyes
  • Diagnosed with TB Meningitis
    • Large suprasellar tuberculoma
    • Causing compression of right ON and optic chiasm
case 4 compressive optic neuropathy1
Case 4: Compressive Optic Neuropathy
  • Visual Acuity: CF OD

20/25 OS

  • Pupils: Fixed pupil on right, with right RAPD (by reverse testing)
  • Ocular Motility: Right third nerve palsy with aberrant renervation
  • Fundi: Bilateral optic atrophy
case 4 compressive optic neuropathy2
OS

OD

Case 4: Compressive Optic Neuropathy
  • Dense central scotoma OD
  • Temporal cut OS
slide28
Case 4: Compressive Optic Neuropathy

MRI: T1-weighted, post Gd

Cystic Suprasellar Mass

case 4 compressive optic neuropathy3
Case 4: Compressive Optic Neuropathy

Mean=40µ

  • profound bilateral RNFL thinning
  • worse in the right eye
  • OCT findings correlated well functional measures of visual integrity

Mean=53µ

case 5 optic neuritis
Case 5: Optic Neuritis?
  • 41-year old woman
  • Developed sudden onset vertigo and nausea in the fall of 2002
  • Developed vision loss (nasal) and a floater and a “sparkle” in the right eye
case 5 optic neuritis1
Case 5: Optic Neuritis?
  • Visual acuity measured 20/20 in both eyes
  • Right RAPD
  • Color Vision 16/16 Ishihara plates in both eyes
  • Fundi: Examination normal
case 5 optic neuritis2
Case 5: Optic Neuritis?
  • The visual field defect persisted
  • Cranial MRI scan normal
  • Orbital CT scan normal
  • CSF analysis normal
case 5 optic neuritis3
Case 5: Optic Neuritis?

OS

OD

  • Mean Deviation – 0.31dB
  • Normal field
  • Mean Deviation -7.55 dB
  • Nasal superior and inferior visual field loss
case 5 multifocal ergs
Case 5: Multifocal ERGs

mERG Trace Arrays

Retinal

view

Retinal

view

OD

OS

  • Multifocal ERG recordings from 61 regions in the central 45 degrees
  • mERG trace arrays appear reduced in inferior and superior temporal retina in OD
  • mERG trace arrays appear normal in OS
case 5 multifocal ergs1
Case 5: Multifocal ERGs

Statistical Probability Maps

OD

OS

SPM

85 normal

eyes

The Patient

  • Statistical probability mapping of response density was normal in OS
  • Reduced response density in inferior and superior temporal retina in OD
  • Correlates with visual field defect in OD
slide36
RNFL
  • RNFL thickness within normal limits OU
  • Good RNFL symmetry between eyes
case 5 optic neuritis4
Case 5: Optic Neuritis?
  • In May, 2003 the patient reported new “sparkles” in the left eye

Summary:

    • Atypical Optic Neuritis
    • MS work-up negative
    • Lack of optic disc pallor
    • Persistent visual field defect
    • Positive visual phenomena and floaters in both eyes
case 5 optic neuritis5
Case 5: Optic Neuritis?
  • Diagnosis: Acute Zonal Occult Outer Retinopathy
case 5 optic neuritis6
Case 5: Optic Neuritis?
  • The clinical distinction between a retinal versus an optic nerve problem may be difficult
  • Ancillary studies such as OCT and mERG can be very useful in this regard
case 6 traumatic optic neuropathy
Case 6: Traumatic Optic Neuropathy?
  • 61-year old woman was hit with a tennis ball in the left temple in October 2002
  • Developed chronic headaches
  • Noted inferior visual field loss in the left eye
  • Referred to the Neuro-Ophthalmology Clinic in January 2003
case 6 traumatic optic neuropathy1
Case 6: Traumatic Optic Neuropathy?
  • Visual Acuity: 20/20 in the right eye and 20/25 in the left eye
  • Pupils: Equal with no RAPD
  • Color Vision: 15/16 Ishihara Plates in the right eye, and 12/16 plates in the left eye
  • Fundi: Normal
case 6 traumatic optic neuropathy2
Case 6: Traumatic Optic Neuropathy?
  • Serology Studies- Normal
  • Cranial/Orbital CT scan- Normal
  • Orbital Ultrasound- Normal
case 6 traumatic optic neuropathy3
Case 6: Traumatic Optic Neuropathy?
  • In April, 2003 the patient developed new visual field loss in the right eye
  • In May, 2003 she noted sparkles, flashes, and floaters in both eyes
case 6 traumatic optic neuropathy4
MD -6.91 dB

MD -0.64 dB

OD

OS

Case 6: Traumatic Optic Neuropathy
  • Visual Fields Obtained in March 2003
  • OD-Normal
  • OS-defects in superior and inferior
case 6 traumatic optic neuropathy5
MD -7.81 dB

MD -2.41 dB

OS

OD

Case 6: Traumatic Optic Neuropathy?
  • Visual Fields obtained in April 2003
  • OD- now developing VF defects
  • OS- visual defects worsened
case 6 traumatic optic neuropathy6
Case 6: Traumatic Optic Neuropathy?

Repeat Examination

  • Visual acuity: 20/25 in both eyes
  • Pupils: equal with no RAPD
  • Color Vision: 12/16 Ishihara Plates in the right eye, and 7.5/16 plates in the left eye
  • Fundi: Normal
case 6 traumatic optic neuropathy7
Case 6: Traumatic Optic Neuropathy?

mERG Trace Arrays

Retinal

view

Retinal

view

OD

OS

  • Multifocal ERGs from 61 regions in the central 45 degrees
  • mERGs from OD are diminished centrally extending to superior nasal retina
  • mERGs from OS show multiple patchy areas of abnormality
case 6 traumatic optic neuropathy8
Case 6: Traumatic Optic Neuropathy

Statistical Probability Maps

OD

OS

  • Statistical probability mapping shows areas of significantly reduced response density centrally and in superior nasal retina in OD
  • OS shows much greater involvement in response density reduction in inferior and superior retina
slide49
RNFL
  • RNFL thickness within normal limits OU
  • Good RNFL symmetry between eyes
case 6 traumatic optic neuropathy9
Case 6: Traumatic Optic Neuropathy?
  • Diagnosis: Acute Zonal Occult Outer Retinopathy
  • Para-neoplastic work-up was recommended by Retinal Specialist
final observations and conclusions
Final Observations and Conclusions
  • Cases 5 & 6 demonstrate the utility of OCT and mERG in differentiation of optic nerve vs retinal insults
  • OCT measurement of RNFL
    • Reproducibility of 10-20 µ
    • Adequate for long-term follow-up of progressive RNFL damage
  • OCT may prove useful in compressive disease in predicting the likelihood of visual recovery based upon remaining RNFL available at time of diagnosis
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