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.

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 OD OS OD OS BCVA: 20/25 20/25 Pupils: 5 to 3 mm OU, No RAPD IOP: 1717 EOM: FullFull CVF:Superonasal Superotemporal defect defect

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 OD: OS: *Inferior camera artifact

Visual Fields (24-2) OD: OS: Left superior homonymous quandrantanopia

Pre-operative MRI Brain Normal brain MRI *Patient is rotated on table, yielding asymmetry between right and left lobes.

Post-operative MRI Brain Anterior, inferior and lateral resection of temporal lobe with cystic hygroma and normal post-operative changes.

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

Treatment plan Observe Observe

Follow-up Year 2 Year 2 Stable visual field defect Stable visual field defect

The Visual Pathway High anatomical variability in the optic radiations Up to 15 mm anteriorly and 15 mm posteriorly (Winston, 2013).

Optic Radiations 3 Bundles (Winston, 2013) : 3 Bundles (Winston, 2013) : Anterior bundle (Meyer’s Loop) – Sharp inferolateral turn to end in lower calcarine fissure Anterior bundle (Meyer’s Loop) – Sharp inferolateral turn to end in lower calcarine fissure Central bundle – passes lateral and posterior to the occipital pole Central bundle – passes lateral and posterior to the occipital pole Posterior bundle – direct posterior course to the upper calcarine fissure Posterior bundle – direct posterior course to the upper calcarine fissure

Optic radiations Patient post-op Diffusion tensor tractography – representative image (Bartroli, 2010)

Temporal lobe surgery Temporal lobe resective surgery (Georgiadis, 2013) : Temporal lobe resective surgery (Georgiadis, 2013) : Broad range of surgical options: Anterior temporal lobe resection, selective amygdalohippocampectomy Broad range of surgical options: Anterior temporal lobe resection, selective amygdalohippocampectomy Newer approaches may spare optic radiations (Winston, 2013) Newer approaches may spare optic radiations (Winston, 2013)

Visual field defects following temporal lobectomy Visual field defects – % Visual field defects – % Most commonly superior quadrantanopia (Piper et al, 2014) Most commonly superior quadrantanopia (Piper et al, 2014) Other noted complications (Georgiadis, 2013) : Other noted complications (Georgiadis, 2013) : Trochlear nerve palsy – 2.6 to 19% Trochlear nerve palsy – 2.6 to 19% Transient oculomotor nerve palsy – 2.1% Transient oculomotor nerve palsy – 2.1% Hemiparesis – 4.6% Hemiparesis – 4.6%

Visual cortex activity outside of scotoma expected from automated perimetry. Population receptive field analysis of primary visual field cortex complements perimetry in patients with homonymous visual field defects. Papanikolaou A, et al PNAS, 11(16):E

References Krolak-Salom P, et al Anatomy of optic nerve radiations as assessed by static perimetry and MRI after tailored temporal lobectomy. British Journal of Ophthalmology, 84: Krolak-Salom P, et al Anatomy of optic nerve radiations as assessed by static perimetry and MRI after tailored temporal lobectomy. British Journal of Ophthalmology, 84: Piper RJ, et al 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: Piper RJ, et al 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: Fong KCS Eye, 17: Fong KCS Eye, 17: Winston GP Epilepsia, 54(11): Winston GP Epilepsia, 54(11): Papanikolaou A, et. Al Proc Natl Acad Sci U S A, 111(16): E1656–E1665. Papanikolaou A, et. Al Proc Natl Acad Sci U S A, 111(16): E1656–E1665. Georgiadis et al Epilepsy Research and Treatment. Georgiadis et al Epilepsy Research and Treatment. Bartroli V be-4ffd-8ebe- 4dfe8cb40854:SetFilter:FilterField1%3d%252540ID%26FilterValue1%3d292 Bartroli V be-4ffd-8ebe- 4dfe8cb40854:SetFilter:FilterField1%3d%252540ID%26FilterValue1%3d292