Optic Nerve
Optic Nerve
Optic Nerve
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.
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.
Clinical Picture
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:
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:
Treatment :
Cause. Optic n. decompression ( if impending atophy). Dehydrating measures e.g. mannitol, steroids. Surgical decompression of orbital walls.
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
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.
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
Tobacco amblyopia
Aggrevated
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:
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:
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
CONSECUTIVE ATROPHY
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
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