Optic Nerve

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By Rania Serag Mohammed Assistant Lecturer of Ophthalmology Ain-Shams University

Anatomy
2nd

cranial nerve. GCL LGB ( visual fibres 80) Pupillary fibres ( 20%) pretectal area of midbrain

Pathway of fibres
ONH

Lamina cribrosa of sclera orbit optic foramen canal cranial cavity. Orbital fibres are myelinated and covered by pia , arachnoid & dura matter. Dura is attached to periorbita.

LAMINA CRIBROSA

Blood Supply:
Intraocular branches of short post ciliary a. and CRA ( circle of Zinn) Intraoribtal pial plexus and CRA from ophthalmic a. Intracanalicular and intracranial pial plexus from ICA ophthalmic anterior cerebral hypophyseal.

Def:

edema of optic disc due to increase ICT. Mechanism: Subarachnoid space around optic nerve is continuous with that of the brain. Increase ICT transmitted around optic nerve compression of CRV running in subarachnoid space and within the substance of optic nerve Optic disc edema and swelling.

SUBARACHNOID SPACE OF OPTIC NERVE

D.D. of papilledema
General causes ( bilateral) Malignant hypertension Acute severe anemia. Local Causes ( unilateral) CRVO Papillitis Hypotony Optic nerve tumours e.g. glioma & meningeoma.

N.B : Pseudopaplilledema Blurred overcrowded disc in hypermetropes.

Clinical Picture

Symptoms: General ( increased ICT)

Local:

Headache ( increased by straining) Projectile vomiting ( no nausea) Disturbed conscious level. VA is normal early, because nerve fibres are loosely arranged in optic disc and can withstand fluids of large amount before compressing them and causing visual symptoms. Late amaurosis fugax ( transient visual obscurations). Very late gradual progressive loss of vision.

Signs:
1.Fundus ( indirect opthalmoscopy)
Papilledema (usually bilateral but assymetrical )

Grading of papilledema:
Early:
Blurred disc margins ( NSIT rule). Engorged retinal veins , with loss of spontaneous venous pulsations ( if already present).

Established Blurred, elevated disc margins above the retinal plane. Cup is obliterated. Veins more engorged + flame shaped hges + cotton wool patches. Cotton wool patches: infarctions of NFL. Flame shaped hges and cotton wool spots are located at or near disc margins but may extend to the macula marked drop of vision.

Chronic:

Secondary ( post papilledemic ) optic atrophy


White disc ( gliosis) Blurred margins.

Hge and exudation resolves. Champaigne cork or mushroom disc. Mild venous congestion.

2) Visual Field

Early enlargement of blind spot ( 3DD temporal and 0.8 mm below point of fixation). Later concentric field contraction ( macular fibres are in the center) Relative scotoma for colours.

Fate of papilledema:

Complete resolution ( if properly managed). Post papilledemic optic atrophy.

Treatment :
Cause. Optic n. decompression ( if impending atophy). Dehydrating measures e.g. mannitol, steroids. Surgical decompression of orbital walls.

Definition : Inflammation of optic nerve.

Optic Neuritis

Causes; Non-infective: Demyelinating diseases e.g. M.S. ( white matter) Toxic e.g. Tobacco, methyl alcohol, ethambutol, orbital cellulitis. Idiopathic. Infective Viral ( most common cause in children) ;measles , mumps, influenza . ) Extension from brain orbit or sinuses. Granulomatous e.g. T.B sarcoidosis. Ischemic AION Arteritic AION temporal artery affected , collagen diseases ( GCA ). Non arteritc AION DM , HTN .

Clinical picture:
Papillitis ( optic nerve head ) or retrobulbar neuritis ( optic nerve).
It can be acute or chronic

Symptoms

Acute optic neuritis:

Rapid drop of vision ( painless in papillitis and painful in retrobulbar neuritis, because meninges are sensitive to pain, increase on upward and medial gaze because superior and medial recti take partial origin from optic nerve sheath. Affected colour vision ( colours are washed out).

Signs: VA reduced

Colour impaired Pupillary reaction RAPD. Fundus Retrobulbar neuritis : Normal appearance. Papillitis: swollen disc , hyperemic, vitritis overlying the disc. AION : pale disc. Field Central or centrocaecal scotoma Relative scotoma for red & green.

COLOUR VISION AFFECTION

OPTIC DISC IN RETROBULBAR NEURITIS AND PAPILLITIS

Treatment:
Cause Steroids affect duration but doesnt improve visual outcome. Complete resolution Incomplete resolution ( colour perception) Recurrence ( e.g. M.S) optic atophy (post- papillitic).

Fate:

Exogenous

ethambutol Destruction of GCL and NFL. Usually bilateral & retrobulbar.


Cyanide

toxins e.g. tobacco, methyl alchohol,

Tobacco amblyopia

Aggrevated

by alcohol and B12 def.

Symptoms: Signs:

Gradual drop of vision Defective colour vision Normal fundus , but late disc pallor Centrocaecal field scotomas for red and green Stop smoking B12 ( hydroxycobolamine).

Treatment

Definition:

Destruction of optic n. fibres at anysite from ganglion cells to LGB of thalamus.


Clinical

Progressive visual loss No PL. Pupillary reflex affected. Pale optic disc with progressive widening of the cup and fibres destruction. Progressive field losses.

picture:

Types:

1.Primary optic atropy

No previous disc or retinal pathology e.g. hereditary Pale white or greyish white disc. Well defined edges Shallow cupping ( saucer-shaped) Surrounding retina looks normal

2.Secondary optic atrophy ( post neuritic or paplilledemic)


Pale white or grayish white disc Blurred edges ( gliosis) Cup is filled with glial tissue. Retina develops RPE proliferation near the disc.

3.Consecutive optic atophy


Following retinal pathology e.g. retinitis pigmentosa, chorioretinitis, CRAO , CRVO . Yellowish waxy disc. Cup is filled with gliosis Evidence of retinal disease

CONSECUTIVE ATROPHY

4.Post glaucomatous optic atophy

Pale whitish disc Well defined edges Deep cupping Vessels appear emerging from edges of disc and bent at edge of neuroretinal rim High IOP Field changes

POSTGLAUCOMATOUS ATROPHY

APPLANATION TONOMETRY

N.B All types are pale white except consecutive ( waxy yellow) All cups are filled with gliosis except primary and post glaucomatous. Retinal vessels are attenuated in all types, but least in primary

THANK

YOU

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