1. Neuro-ophthalmology
sjtu ophthalmology 樊莹

2. Neuro-ophthalmology an important sensory end organ
intimatedly related to the brain
cranial nerves: 50％ II、III、IV、V、VI、VII
cranial nerve fiber: 38％
intracranial diseases: 65％
vision loss blindness die
diagnosis including etiology and location

3. optic neuropathy

4. structure of retina

5. nerve fiber layer

6. sensory visual pathway

8. anatomy of the optic nerve
from optic disc to optic chiasm
length：45~50mm
including：intraglobe mm
intraorbit 25~30 mm
optic canal mm
intracrania mm

9. histology of the optic nerve
comprised by ganglion cell axons
covered by meninges (3 layers)
lack of Schwann's cells
hard to rebuild

11. to valuate optic nerve morphology：ophthalmoscope ultrasonic
X-ray CT MRI
function：vision acuity visual field
pupil test VEP+ERG
dark adaption colour perception

12. visual field testing steady fixation
measure the comdined function of the retina
“peripheral vision”
<30°central visual field
>30°peripheral visual field

13. kinetic perimetry

14. static perimetry

15. electrophysiologic testing
electrooculogram EOG
electroretinogram ERG
visual evoked potential VEP

17. pupil

18. light reflex
normal
abnormal

19. optic neuropathy inflammatory： optic neuritis vascular：
anterior ischemic optic neuropathy (AION)
neoplastic infiltration：
glioma, leukaemia, lymphoma,
meningeal carcinomatosis
others：
optic atrophy、papilledema

20. Optic neuritis duo to a variety of causes
the most common is demyelination
else: immune-mediated
direct infections
granulomatous optic nueropathy
contiguous inflammatory disease

21. demyelinative optic neuritis
clinical features:
chiefly in women(3:1) chiefly in white
associated with multiple sclerosis
subacute(2~7days)
color vision and contrast sensitivity impaired
pain(in eye 90%)(by eye movement 50%)
abmormal in pupil testing
change in VEP
a central scotoma in most cases
brain MRI (necesssary)
including: papillitis
retrobulbar neuritis

22. Papillitis
in 35% cases
hyperemia of the optic disk and large veins(early signs)
edema (nearly more than 3D) (common)
blurring of the disk margins (common)
filling of the physiologic cup (common)
retinal exudates and edema (uncommon)
hemorrhage (uncommon)
vitreous cells (uncommon)

23. Papillitis
Fundus

24. Papillitis
FFA

25. Papillitis CT
Visual field

26. Retrobulbar neuritis vision loss
no obvious changes in the optic disk (at earlier stage)
secondary optic atrophy

27. demyelinative optic neuritis
differential diagnosis:
compressive optic neuropathy
anterior ischemic optic neuropathy
autoimmune optic neuropathy
toxic amblyopia
Leber's hereditary optic neuropathy
vitamin B12 deficiency
papilledema

28. demyelinative optic neuritis
treatment:
steroid therapy
can accelerate recovery of vision
can not influence the ultimate visual outcome
may increase the risk of recurrency
intravenous steroid therapy
useful for multiple sclerosis

29. anterior ischemic optic neuropathy (AION)
due to infarction of the retrolaminar optic nerve from occlusion or decreased perfusion of the short posterior ciliary arteries

30. vessels of the optic nerve

31. AION causes: arteriosclerosis diabetes hypertension hyperlipidemia
intracranial stroke
vasculitis,migraine,inherited prothrombotic states(in younger patients)
reduced cup,optic nerve head drusen,increased intraocular pressure

32. AION clinical features: in the sixth or seventh decade
vision loss without pain
generally abrupt,progressive
altitudinal vision field defects()
FFA:decreased perfusion
segmented the nonarteritic form
diffuse the arteritic form
disk leakage the late phase

33. AION

34. AION

35. AION
treatment:
No treatment has been shown to provide long-term benefit.
Low-dose aspirin may reduce the risk of involvement of the fellow eye.
identify the arteritic AION (high-dose systemic steroids)

36. Papilloedema
noninflammatory congestion due to raised intracranial pressure
causes
intracranial mass
abscesses
subdural hematoma
arteriovenous malformation
subarachnoid hemorrhage
meningitis or encephalitis
acquired hydrocephalitis
else

37. Papilledema increased intracranial pressure axonal transpot is blocked

38. Papilledema clinical features:
normal vision in most cases for early papilledema
1~2days to occur and 1 week to develop fully
severe vision loss for late papilledema

39. Papilledema
the early stage

40. papilledema
the middle stage

41. papilledema
the late stage

42. papilledema
FFA

43. papilledema differential diagnosis: burid drusen of the optic nerve
small hyperopic disks
AION
myelinated nerve fibers

44. papilledema
treatment:
deal with the underlying cause

45. Optic atrophy
primary optic atrophy
secondary optic atrophy

46. primary secondary + - papilledema axonal fiber atrophy
proliferation of glia -
pale disk
papilledema
blurring of margin
retinal vessels
normal
abnormal

47. Optic atrophy

48. Optic atrophy
treatment: to the underlying cause

49. optic nerve tumor
glioma of optic nerve
meningioma of optic nerve

50. Glioma of optic nerve

51. Glioma of optic nerve

52. Meningioma of optic nerve

53. Meningioma of optic nerve

54. optic nerve tumor
treatment: operation

55. the optic chiasm

56. 视交叉病变

58. the optic chiasm diseases
pituitary adenoma
craniopharyngioma
tuberculum sellae meningioma
chiasmatic and optic nerve gliomas

59. pituitary adenoma

60. the retrochiasmatic visual pathways
cortical blindness
macular sparing
macular splitting

62. cases