Optic Nerve Anomalies - Acquired Flashcards
What is papilloedema?
•Papilloedema is a swelling of the ON secondary to raised intra-cranial pressure
Is papilloedema unilateral or bilateral?
•Papilloedema is typically bilateral but may be asymmetric
What is the managment for papilloedema?
•Any patient presenting with papilloedema should be suspected of having an intracranial mass and referred immediately
What are the symptoms associated with papilloedema?
- VA not affected initially but increase in size of blind spot as progresses
- Blurred vision – transient when rising to stand
- Double vision (VIth nerve palsy)
- May have RAPD
- Headaches – worse after lying down - this is a big indication
- Nausea
- Vomiting
What does early papilloedema look like?
- Mild disc swelling and hyperaemia - nasal margins affected first
- Blurring of disc margins
- Venous engorgement (i.e. veins getting bigger is the first sign)
What may established papilloedema present with?
- Disc swelling
- Cotton wool spots
- Retinal folds
- Hard exudates
What is atrophy?
The wasting away or deterioration of something
What are symptoms and signs of optic atrophy?
- Progressive loss of vision
- Colour Vision, VF and VA all affected
- Disc appears pale
What are the two types of optic atrophy- describe each one.
Primary and Secondary
•Primary
- This is optic atrophy that is not associated with another disease
- It is often hereditary - (most common is Leber’s hereditary optic neuropathy – loss of vision in one eye or both in teens or twenties)
•Secondary
- Associated with another disease
- Usually Alcohol/tobacco or Drug induced.
What is the management of Optic Atrophy?
- It is Irreversible
- If not noted previously then referral to HES – speed depends on VA and whether progressive or not (from patient’s symptoms)
What may optic neuritis be caused by?
- Optic neuritis is caused by inflammation, infection or demyelination of the optic nerve
- Para-infectious causes may occur due to a viral infection or immunisation
- Infectious causes may be due to syphilis, lyme disease and cat-scratch fever
- Can be idiopathic
What is the most common cause of optic neuritis?
Demyelination as a result of a disease such as Multiple Sclerosis
What is multiple sclerosis (MS)?
- Multiple Sclerosis (MS) is a disease of the central nervous system where there is demyelination of the nerve fibres
- Demyelination can occur anywhere in the body causing neural and muscular impairments which can be mild or severe
Whom does optic neuritis most commonly affect?
•Patients usually present between the ages of 20 and 40 – majority are female (3:1)
What is optic neuritis often refered to as and why?
•As ON appears normal - condition sometimes referred to as ‘retrobulbar neuritis’
What is the managment of optic neuritis?
- Recovery begins within 2-3 weeks – maximal after 6 months
- 75% recover VA of 6/9 or better
- disease associated with relapses - so you have to keep an eye on the px
- Treatment may delay further relapses
- Refer – soon if due to demyelination
What is an infarct?
A small localized area of dead tissue resulting from failure of blood supply.
What is Anterior Ischaemic Optic Neuropathy and hwo does it occur?
It is an Infarct of the ONH – tissue death due to inadequate nerve supply.
It is due to an occlusion of the short posterior ciliary arteries
What visual field loss is anterior ischaemic optic neuropathy associated with?
Associated with altitudinal hemianopia
What is the visual prognosis of someone with anterior ischaemic optic neuropathy?
Visual prognosis is poor and VA/VF loss is permanent
What are the two types of Anterior Ischaemic Optic Neuropathy (AION) and whom are they most common in?
- Non-arteritic – NAION (not associated with arteritis) is more common more likely to occur in younger individuals
- Arteritic - AAOIN (associated with arteritis) is more likely to occur in older individuals
What are the symptoms associated with Non-Arteritic Anterior Ischaemic Optic Neuropathy?
Patients present with severe, painless, sudden loss of vision
What are the signs of Non-arteritic Anterior Ischaemic Optic Neuropathy?
- Pale swollen disc
- Surrounding haemorrhages
What is Non-arteritic Anterior Ischaemic Optic Neuropathy associated with?
- ‘At risk’ discs – small or absent cup – crowded disc – in conjunction with with hyperopia
- Impaired circulation as opposed to inflammation so could be due to (i) hypertension or (ii) diabetes or (iii) high cholesterol levels
What is the managment for Non-Arteritic Ischaemic Optic Neuropathy?
- No treatment possible
- 30% lose vision in other eye within two years
- Refer to casualty – arteritis (and so arteritic Anterior Ischaemic Optic Neuropathy) needs to be excluded
What is so concerning about Arteritic Anterior Ischaemic Optic Neuropathy?
It is a sight and life threatening condition
What may arteritic Anterior Ischaemic Optic Neuropathy also be called?
Can be referred to as Giant Cell Arteritis (GCA)/Temporal arteritis
What is Arteritic Anterior Ischaemic Optic Neuropathy caused by?
•Caused by inflammation of the small and medium arteries around the ONH – especially the temporal, ophthalmic and posterior ciliary arteries.
What are symptoms of Artertic Anterior Ischaemic Optic Neuropathy?
- Sudden profound painless unilateral loss of vision
- Age usually between 60 to 80 years
- Jaw claudication
- Scalp tenderness
- Temporal headache
- Tender inflamed nodular arteries – can see in the picture
- Weight loss
- Fever night sweats
- Might experience TIA (Transient Ischaemic Attacks)
What is the management for Arteritic Anterior Ischaemic Optic Neuropathy?
- Following immediate referral patients - temporal artery biopsy and bloods taken – check for raised erythrocyte sedimentation rate (ESR) check to confirm diagnosis
- High dose steroid required to decrease inflammation (this is done even without confirmed diagnosis just incase px does have the arteritic kind)
- High dose of steroid Can help to preserve sight in the remaining eye even though VA in affected eye does not recover
- Steroids also reduce risk of cerebral vascular accident
True or False- 2/3rds of px with optic neuritis will show a normal fundus
True
