Disc edema ,papilloedema & optic neuritis

difference between disc odema & optic nerve swelling ?
papillodema ? causes ?

1. DISC EDEMA , PAPILLOEDEMA & OPTIC NEURITIS TREATMENT & INVESTIGATIONS Dr. SHARAD ,SCEH , LAHAN O.A 2 nd Year

2. OPTIC NEURITIS Optic neuritis includes inflammatory and demyelinating disorders of the optic nerve . Inflammation of optic nerve is called OPTIC NEURITIS . optic nerve : Each optic nerve (second cranial nerve) starts from the optic disc and extends up to optic chiasma, where the two nerves meet. Parts of optic nerve. The optic nerve is about 47–50 mm in length, and can be divided into 4 parts: intraocular (1 mm), intraorbital (30 mm), intracanalicular (6-9 mm) and intracranial (10 mm).

3. Etiology of optic neuritis Idiopathic Hereditary optic neuritis ( Leber’s disease) Demyelinating disorders : multiple sclerosis, neuromyelitis optica ( Devic’s disease ) About 70% cases of established multiple sclerosis may develop optic neuritis Parainfectious optic neuritis is associated with various viral infections such as measles, mumps, chickenpox, whooping cough and glandular fever. It may also occur following immunization Toxic optic neuritis after methyl alcohol intoxication , smoking & tobacco use .

4. Infectious optic neuritis may be sinus related (with acute ethmoiditis) or associated with cat scratch fever, syphilis (during primary or secondary stage), tuberculosis and cryptococcal meningitis in patients with AIDS. Autoimmune disorders associated with optic neuritis include sarcoidosis, systemic lupus erythematosus, polyarteritis nodosa, GuillainBarre syndrome and Wegener’s granulomatosis

5. Clinical Profile & Anatomical types Papillitis. It refers to involvement of the optic disc in inflammatory and demyelinating disorders. This condition is usually unilateral but sometimes may be bilateral. Neuroretinitis refers to combined involvement of optic disc and surrounding retina in the macular area. Retrobulbar neuritis is characterized by involvement of optic nerve behind the eyeball .

6. Typical versus atypical optic neuritis The term typical optic neuritis refers to the one associated with demyelination, particularly multiple sclerosis and the term atypical neuritis is labeled for the one associated with causes other than demyelination disorders.

7. Clinical features & Symptoms. Optic neuritis may be asymptomatic . Visual loss. Monocular sudden, progressive and profound visual loss . Dark adaptation may be lowered . Visual obscuration in bright light is a typical symptom of acute optic neuritis. Impairment of colour vision is always present in optic neuritis

8. Movement phosphenes and sound induced phosphenes may be perceived by patients with optic neuritis. What is phosphens ?? : Phosphenes refer to glowing sensations produced by nonphotic or the so called inadequate stimuli .

9. Uhthoff’s symptom : Episodic transient obscuration of vision on exertion and on exposure to heat, which recovers on resting or moving away from the heat . Pulfrich’s phenomenon : Depth perception, particularly for the moving object may be impaired . Ocular pain : It is more marked in patients with retrobulbar neuritis than with papillitis , pain on extraocular movements .

10. papillitis ( disc odema ) & neuroretinitis

11. In summary

12. Visual field changes. The most common field defect in optic neuritis is a relative central or centrocaecal scotoma. The field defects are more marked to red colour than the white colour . Contrast sensitivity is impaired. Visually evoked response (VER) shows reduced amplitude & delay in the transmission time. RAPD . Marcus – Gun reflex Sometimes inflammatory cells in vitreous seen ( vitritis )

13. Disc become odematous & hyperaemic physiological cup is obliterated ( in papillitis disc oedema rarely exceeds 2–3 D , while in papilloedema it become 3–6 D ). Retinal veins are congested and tortuous. Splinter haemorrhages seen .

14. D/D Papillitis should be differentiated from papilloedema ischaemic optic neuropathy anterior orbital compressive neuropathy and pseudopapilloedema high hypermetrpic disc

15. D/D OF RBN ( retrobulbar neuritis ) Acute retrobulbar neuritis. It must be differentiated from malingering hysterical blindness & cortical blindness Complications of optic neuritis is mostly optic atrophy leads to complete vision loss .

16. Investigations : MRI / CT scan : to rule out demyelinating cause like multiple sclerosis CBC ( complete blood count ) Mantoux test : for T.B / Kochs disease VDRL , HIV & HBsAg Other investigation depends on etiology

17. treatment of optic neuritis 1. Treatment of the causes. Efforts should be made to find out and treat the underlying cause . 2. Corticosteroid therapy Optic neuritis treatment trial (ONTT) group has made following recommendations for the use of corticosteroids:

18. Other treatment consist : methylcobalamine injection ( vitamin B12 ) CAUSES OF OPTIC DISC SWELLING & optic nerve swelling …..……………………….. …………………… Next slide

19. Papilloedema ‘ papilloedema ’ has been reserved for the passive disc swelling associated with increased intracranial pressure which is almost always bilateral although it may be asymmetrical .

20. etiology 1 . Congenital conditions include aqueductal stenosis and craniosynostosis 2. Intracranial space-occupying lesions (ICSOLs). These include brain tumours, abscess, tuberculoma, subdural haematoma & aneurysms. The ICSOLs in any position excepting medulla oblongata may induce papilloedema . 3. Intracranial infections such as meningitis and encephalitis may be associated with papilloedema 4. Intracranial haemorrhages . Cerebral as well as subarachnoid haemorrhage 5 . Obstruction of CSF absorption 6. Tumours of spinal cord 7. Diffuse cerebral oedema from blunt head trauma

21. 8. Idiopathic intracranial hypertension (IIH) also known as pseudotumour cerebri, is an important cause of raised intracranial pressure . 9. Systemic conditions include malignant hypertension, pregnancy induced hypertension (PIH) . Visual fields. Blind spot is enlarged and the visual fields begin to constrict.

22. Clinical features A. General features Patients usually present to general physicians with general features of raised intracranial pressure. These include headache, nausea, projectile vomiting and diplopia. Clinical features of papilloedema can be described under four stages: early, fully developed, chronic and atrophic.

23. Pseudopapilloedema is a non-specific term used to describe elevation of the disc similar to papilloedema , in conditions such as optic disc drusen, hypermetropia & and persistent hyaloid tissue .

24. treatment and prognosis Papilloedema is a neurological emergency and requires immediate hospitalisation . Urgent neuroimaging (CT scan or preferably MRI with a gadolinium enhancement) may reveal primary pathology. As a rule unless the causative disease is treatable or cerebral decompression is done . The course of papilloedema is chronic and ultimate visual prognosis is bad.

25. HOME WORK ? What are the causes of disc odema ? Name the condition where both patient & doctor can not see………….. Name some differential diagnosis of optic nerve swelling ? What is optic neuritis ? What are the three types ? Name only What are mechanical & vascular ( neurological ) signs of optic neuritis ? Explain in brief management of optic neuritis ? Investigations ? What is the difference between disc odema & papillodema ? Enumerate causes of papillodema ? & management of that ? What is ONTT…………………. ? Name single demyelinating condition in which 70% cases of optic neuritis present ……………………. ?