糖尿病性视神经病变的OCT图像特点分析

目的：回顾分析糖尿病性视神经病变( diabetic optic neuropathy, DON )的相干光断层成像( optical coherence tomography,OCT)的特点。
　　方法：回顾性系列病例研究。选择2013-12/2015-10西安交通大学医学院第二附属医院眼科门诊和内分泌科会诊期间诊断为2型糖尿病且伴有眼底病变的患者175例350眼的临床资料,记录患者的全身检查情况和疾病史,阅读所有患者的彩色眼底照相、荧光素眼底血管造影( fluorescein fundus angiography,FFA)、OCT的影像结果,并进行分析统计。
　　结果：通过FFA 检查视乳头具有异常荧光表现,确定有DON的有49例90眼,占25.7%。 OCT结果显示DON 90眼中15眼(16.7%)表现为视神经形态大致正常;20眼(22.2%)表现为视杯凹陷变小或消失,筛板前组织肿胀,同时伴有盘周神经纤维层水肿;26眼(28.9%)表现为视杯深陷,杯盘比变大;18眼(20.0%)表现为视盘内或视盘表面组织增生;11眼(12.3%)玻璃体视乳头牵拉,视盘边缘抬高。在FFA中有相同荧光表现的DON患眼,在OCT检查可表现出不同的组织形态。
　　结论：FFA从视神经的血循环状态变化定义DON,而OCT可以发现FFA所不能显示的视神经组织形态的变化,从而更清晰视神经病变的位置和原因,为治疗提供依据。OCT无创、快捷、费用低、可重复性强等优点有利于DON患者的复查及治疗效果追踪。     

Clinical Features of Optic Neuritis in China

Objective: To document the clinical features of optic neuritis in a population of China and compare with reports of Western countries. Background: Optic neuritis is a common optic neuropathy well studied in Western countries. In English literature very few studies addressed optic neuritis in China. Method: Retrospective medical chart review of all patients admitted in a teaching hospital from 2002 to 2005 with a final diagnosis of idiopathic demyelinating optic neuritis. Results: Ninety-eight patients including 45 men and 53 women were collected, with a mean age of 25.7 years. Sixty-six cases (67.3%) were unilateral optic neuritis and 32 (32.7%) were bilateral. Eye pain was reported in 42 cases (42.9%). Visual acuity in 130 affected eyes varied from 0.8 to no light perception, with 0.1 or worse in 101(77.7%), between 0.1 and 0.4 in 15 (11.5%) and 0.5 or better in 14(10.8%). Fifty-two eyes (40%) showed disc swelling. Central scotoma was the most common (61%) localized visual field defect. Optic nerve enhancement was found in 85 of 121 eyes (70.2%) while 15 cases (15.3%) showed periventricular plaques in brain MRI. Positive oligoclonal band or elevated myelin basic protein was found in 17 (17.3%) cases. Eight (8.2%) cases met the criteria of clinical definite multiple sclerosis and 4 cases had neuromyelitis optica. Visual acuity of 35 eyes (26.9%) improved to 1.0 or better while 37 eyes (28.5%) remained 0.1 or worse at the 3-month follow-up. Conclusion: Clinical features of optic neuritis in a population of China were documented. Less ocular pain, less brain MRI abnormalities, more severe visual loss and poor visual outcome were seen compared to reports of Western countries.     

Optic neuropathy complicating multifocal choroiditis and panuveitis

PURPOSE: To describe the clinical characteristics of patients with optic neuropathy complicating multifocal choroiditis and panuveitis (MFCPU). DESIGN: Retrospective case series. METHODS: Eight patients (11 eyes) with MFCPU and optic neuropathy from a single center were reviewed and clinical outcomes described. RESULTS: The median age of patients was 45 years; six patients were women and seven were Caucasian. In the six patients with available follow-up, the optic neuropathy was corticosteroid-responsive, but required corticosteroid treatment to prevent recurrences of optic nerve inflammation and subsequent vision loss. Five patients required immunosuppressive drug therapy during their treatment course. No patients had recurrence of optic neuropathy while receiving immunosuppressive drug therapy. Visual acuity improved or stabilized with treatment in nine of 11 affected eyes. CONCLUSIONS: Optic neuropathy is an uncommon complication of MFCPU that may result in substantial visual morbidity. Immunosuppressive drug therapy may prevent recurrences of optic neuropathy and subsequent vision loss.     

Perineural metastasis of breast cancer treated with optic nerve sheath fenestration

A 36-year-old woman with bilateral optic neuropathy and orbital and central nervous system metastasis from breast carcinoma developed progressive bilateral vision loss with severe optic disc swelling. She underwent optic nerve sheath fenestration of the left eye resulting in modest improvement in vision and resolution of disc edema. Optic nerve sheath fenestration is a known treatment for papilledema, but its effectiveness as a treatment for an optic neuropathy caused by perineural or intrasheath metastasis is less clear. Optic nerve sheath fenestration should be considered as a treatment option for an optic neuropathy caused by perineural or intrasheath metastasis, especially in cases where alternative treatments are not tolerated and visual loss is severe at presentation.     

Disc excavation in dominant optic atrophy: differentiation from normal tension glaucoma

OBJECTIVE: In patients with dominant optic atrophy (DOA, Kjer type), excavation of the optic nerve develops, and these patients may be misdiagnosed as having normal tension glaucoma (NTG). This study examined disc morphologic features in patients with DOA and explored features that help distinguish this condition from NTG. DESIGN: Noncomparative, observational case series. PARTICIPANTS: Patients with DOA who were seen at the Duke University Eye Center between 1987 and 1996 and who had bilateral optic nerve photographs. METHODS: Retrospective chart review of the results of visual acuity testing, visual field testing by Goldmann perimetry, color vision testing, intraocular pressure measurement, and observation of bilateral optic nerve photographs. MAIN OUTCOME MEASURES: Appearance of the optic disc and peripapillary zone in patients with DOA. RESULTS: Nine patients were identified. The mean age at the time of evaluation was 28 years (range, 11-62 years). Most patients had a mild to moderate reduction in visual acuity. Color vision as tested with Hardy-Rand-Rittler plates was reduced (4.0/10 +/- 4.2/10). A cup-to-disc ratio of more than 0.5 was observed in at least one eye of eight patients. A temporal wedge-shaped area of excavation was observed in 14 of the 18 eyes studied. Moderate to severe temporal pallor was observed in all of the eyes. Pallor of the remaining (noncupped) neuroretinal rim was also observed consistently, ranging from mild to moderate. A gray crescent and some degree of peripapillary atrophy were noted in all eyes. CONCLUSIONS: Several clinical features, including early age of onset, preferential loss of central vision, sparing of the peripheral fields, pallor of the remaining neuroretinal rim, and a family history of unexplained visual loss or optic atrophy, help to distinguish patients with DOA from those with NTG.     

后部缺血性视神经病变临床观察

目的:通过回顾性研究,探讨后部缺血性视神经病变(pos-teriorischemicopticneuropathy,PION)的临床表现、发病机制、诊断及治疗预后。方法:对9例(12眼)PION患者常规行眼部检查及全身检查,并排除压迫性、炎性、青光眼性或其它视神经疾病。行中医综合治疗。观察视力、视野、眼前节及眼底体征。结果:9例12眼均有不同程度视力下降及视野缺损;眼底视盘及视网膜正常6眼,视盘变淡或苍白6眼。经治疗的8例10眼,有效率70%。结论:PION是一种独立的临床眼病,诊断强调排除其它视神经疾病或眼病,中医综合治疗有助于视力改善。     

Dysthyroid optic neuropathy (DON)

Dysthyroid Optic Neuropathy (DON) affects a small percentage of patients with Graves disease, but, when it occurs, it can cause significant and permanent loss of vision. DON is treatable if recognized early. Systemic steroids can be effective, but may cause side affects. Orbital injection of steroids may play a role in selected patients. Orbital radiation has a more permanent effect and has gained wide acceptance as a relatively non-invasive method of reversing DON. Surgery to decompress crowded orbits has been used for years and continues to be a viable approach for those patients with optic neuropathy, especially when there is significant proptosis. Optic nerve decompression can also be achieved through a transethmoidal approach.     

Dysthyroid optic neuropathy (DON)

Dysthyroid Optic Neuropathy (DON) affects a small percentage of patients with Graves disease, but, when it occurs, it can cause significant and permanent loss of vision. DON is treatable if recognized early. Systemic steroids can be effective, but may cause side affects. Orbital injection of steroids may play a role in selected patients. Orbital radiation has a more permanent effect and has gained wide acceptance as a relatively non-invasive method of reversing DON. Surgery to decompress crowded orbits has been used for years and continues to be a viable approach for those patients with optic neuropathy, especially when there is significant proptosis. Optic nerve decompression can also be achieved through a transethmoidal approach.     

Anterior ischemic optic neuropathy associated with Vogt–Koyanagi–Harada disease

Background

Optic disc swelling is a common finding associated with Vogt–Koyanagi–Harada disease (VKH); however, visual field loss from optic disc involvement is uncommon. This reports report presents recent findings regarding unusual patients with visual field defects from optic disc involvement, thus suggesting the presence of anterior ischemic optic neuropathy (AION) in the acute phase of VKH.

Methods

Observational case series. A consecutive series of 52 patients with VKH (6 complete VKH, 46 incomplete VKH) was reviewed. Fifteen patients in this series had optic disc swelling, and six of them developed irreversible visual field defects in the acute phase of VKH. The clinical features of these six patients were analyzed.

Results

The patients with associated visual field loss were four males and two females between 54 to 79 years of age. They had bilateral panuveitis associated with meningismus. All of the patients had bilateral optic disc swelling and fluorescein angiography showed both a filling delay and late leakage of the optic disc. Visual field examinations revealed various degrees of visual field defects in 11 eyes. They were treated with high-dose corticosteroid therapy, and several weeks later, both the uveal inflammation and optic disc swelling disappeared. The visual fields showed some improvement as the retinal detachments and disc swelling resolved, but the visual field defects remained in ten eyes. The small and localized visual field defects were asymptomatic. Subsequently, optic disc pallor developed in nine eyes and retinal nerve fiber layer thickness, measured by optical coherence tomography, was decreased in six eyes. The fundus gradually showed various degrees of hypopigmentation, but did not show any chorioretinal atrophy causing visual field loss. Four patients had risk factors for AION, including diabetes mellitus or a relatively small optic nerve head.

Conclusions

In this consecutive series of patients with VKH, 15 out of 52 patients were found to have disc swelling, and six patients, who were mostly elderly, had associated visual field loss, which is probably due to AION associated with VKH.     

Arachnoid cyst of the optic nerve: report of two cases and review of the literature

PURPOSE: To describe two patients with arachnoid cysts of the optic nerve mimicking optic nerve/orbital neoplasms. METHODS: The histories, ophthalmic examinations, and pathologic findings of two patients with arachnoid cysts of the optic nerves were reviewed and compared with previously reported cases. RESULTS: One patient had progressive proptosis and the other had decreased vision with visual field changes. Pathologic examination of optic nerve sheath biopsies showed redundant proliferations of meningothelial cells with associated thickened dura. CONCLUSIONS: Arachnoid cysts of the optic nerve are benign, slowly progressive conditions that may result in proptosis and visual field changes. The clinicopathologic features of arachnoid cyst should be differentiated from optic nerve sheath meningioma and other conditions.     

Optic nerve sheath meningiomas. Clinical manifestations

A retrospective clinical study of optic nerve sheath meningiomas based on 22 patients showed that symptoms most commonly develop in women between the ages of 35 and 60 years. The most common presenting symptoms were decreased vision and transient visual obscurations. In the earliest stages, many patients presented with normal to mildly impaired acuity (despite subjectively decreased vision), optic disc edema and enlargement of the blind spot. Optic disc edema was frequently associated with refractile bodies indicative of chronic swelling. Optic disc edema preceded the development of optic atrophy. Another group of patients presented with a history of longstanding vision loss, visual acuity of 20/200 or worse and optic atrophy. Optociliary shunt vessels were late findings only seen in five patients. The most consistent visual field abnormality was peripheral constriction. Cecocentral scotomas were uncommon. Intracranial involvement was present in five patients. There were two patients with bilateral optic nerve sheath meningiomas without CT evidence of intracranial involvement. Computerized tomography was found to be indispensable in the diagnosis of optic nerve sheath meningiomas and the detection of intracranial involvement.     

Papilläre Hämodynamik bei Patienten mit Normaldruckglaukom und Papillenrandblutungen

Background. Optic disc hemorrhages in patients with normal-pressure glaucoma (NPG) are usually regarded as a sign of vascular dysfunction and as an indicator for glaucoma damage progression. Methods. Optic nerve head blood flow was measured in 21 patients suffering from NPG with acute optic disc hemorrhages by scanning laser Doppler flowmetry at various locations of the optic disc. Intraocular pressure and mean deviation of the visual field were also monitored. Two groups served as control: 21 patients with NPG matched for age, sex, and stage of the disease and in addition the contralateral eye without any hemorrhages. Results. Optic nerve head blood flow as a mean of several locations was significantly lower in eyes with optic disc hemorrhages than in controls and differed significantly from the contralateral eye. Conclusion. Optic nerve blood flow was lower in NPG eyes with optic disc hemorrhages than in the contralateral eye and in controls.     

甲状腺相关眼病眼眶减压术的疗效分析

目的：探讨眼眶减压术在甲状腺相关眼病中治疗的价值。方法：回顾性分析中山眼科中心1993－2000年27例（30只眼）经全身和眼部临床检查（视力、视野或视觉诱发电位等）确诊为甲状腺相关眼病患者采用眼眶减压术（一壁、二壁及三壁减压）治疗的临床资料,观察其手术前和手术后患者视力、眼球突出度及眼球运动的变化。术后随访2个月至7年,平均13．7个月。结果：视力：19只眼（63．3％）明显提高;4只眼（13．3％）轻度提高,视力均保持在0．2－0．8;4只眼（13．3％）视力无变化,其中3只眼（10．0％）视力下降。24只眼（80．0％）眼球突出后退≥3．0mm,28只眼（93．3％）眼球突出后退≥2．0mm,平均眼球突出后退3．6mm。结论：眼眶减压术可提高甲状腺相关眼病患者的视力,减轻其眼球突出度。     

Optic disc progression and rates of visual field change in treated glaucoma

Purpose: To investigate the relationship between optic disc progression and rates of visual field (VF) change in patients with treated glaucoma. Methods: Glaucoma patients with repeatable VF loss, ≥8 SITA‐Standard 24‐2 VF tests and good quality optic disc stereophotographs evaluated over a 10‐year period were included. Optic disc photographs were reviewed for signs of glaucoma progression (neuroretinal rim change, widening of retinal nerve fibre layer defect, disc haemorrhage and enlargement of beta‐zone parapapillary atrophy) by two glaucoma specialists masked to their temporal sequence. Disagreements were adjudicated by a third grader. VF progression was evaluated using automated pointwise linear regression (PLR) and defined as at least two adjacent test points progressing >1.0 dB/year at p < 0.01. VF progression outcomes were compared with photograph review results. Results: Three‐hundred and eighty nine eyes (389 patients; mean age 64.9 ± 13.0 years; mean baseline MD, ?7.1 ± 5.1 dB) were included. Most patients had primary open angle glaucoma (54%). Eighty‐two eyes (21%) had confirmed optic disc progression and 115 eyes (29%) met the VF PLR criteria. Eyes with documented optic disc progression had more rapid rates of VF change (?0.66 ± 0.7 versus ?0.36 ± 0.7 dB/year, p < 0.01) and met the VF PLR endpoint more often (univariate OR = 1.85, p = 0.02; multivariate OR = 1.78, p = 0.03) than eyes without optic disc progression. There was moderate spatial consistency between the location of the optic disc progression and the hemifield with more rapid progression (81%, kappa = 0.40). Conclusions: Treated glaucomatous eyes with documented optic disc progression are at increased risk of diminished visual function over time and may require more aggressive therapy to prevent future vision loss. Among the indicators of structural progression, disc haemorrhage was the single most significant predictor for VF deterioration.     

Acute visual loss due to a calcified optic nerve glioma

Optic nerve gliomas are slow-growing tumours most commonly seen in children under 10 years of age. Rapidly progressive proptosis and rapid visual deterioration are uncommon but may occur owing to accumulation of mucoid material, necrosis or hemorrhage. We describe a patient with an optic nerve glioma who manifested sudden proptosis and blindness caused by hemorrhage within the optic nerve sheath. The visual acuity returned to 20/25 after surgical decompression of the nerve and high-dose steroid therapy. Histopathological examination was required to establish the diagnosis of optic nerve glioma with extensive calcification. Optic nerve decompression or short-term high-dose steroid therapy, or both, may be helpful in recovering visual function in selected patients with optic nerve gliomas who have acute visual loss.     

Optic nerve sheath decompression for visual loss in intracranial hypertension: report from a tertiary care center in South India

Aim: Severe visual loss is the only serious complication of intracranial hypertension secondary to idiopathic intracranial hypertension (IIH) and some cases of cerebral venous thrombosis (CVT). Optic nerve sheath decompression (ONSD) has been shown to improve or stabilize visual function in patients with IIH, while its role in CVT is yet to be established. We report our experience with optic nerve sheath decompression for visual loss in IIH and CVT. Materials and Methods: In this prospective noncomparative, interventional study, 41 eyes of 21 patients with IIH and CVT and visual loss underwent ONSD. The main outcome measures included best-corrected visual acuity (BCVA), visual fields, pupillary light reflex, optic nerve sheath diameter on B-scan and resolution of papilledema which were evaluated preoperatively and at follow-up at four days, two weeks, one month, three months and final follow-up. In 7/41 eyes with absent light perception preoperatively, the functional outcome was analyzed separately. Results: Following ONSD BCVA and visual fields stabilized or improved in 32/34 (94%) eyes. Statistically significant improvement in BCVA, visual fields and pupillary light reflex occurred over the three month follow-up period. Surgical success was indicated by reduction in optic nerve diameter and papilledema resolution occurred in all patients. The outcome in the IIH and CVT groups was comparable. Four eyes with absent light perception showed marginal improvement in visual acuity. Four eyes had transient benign complications. Conclusion: Optic nerve sheath decompression is an effective and safe procedure to improve or stabilize vision in patients with visual loss caused by IIH and CVT.     

Laser in situ keratomileusis-induced optic neuropathy

OBJECTIVE: To report a case of bilateral optic neuropathy after bilateral laser-assisted in situ keratomileusis (LASIK) surgery. DESIGN: Observational case report. METHODS: Complete eye examination with detailed evaluation of the optic nerve, detailed medical history, stereo disc photographs, GDx Nerve Fiber Analyzer testing, Humphrey 24-2 SITA visual field testing, diurnal intraocular pressure measurement, serologic evaluation, and magnetic resonance imaging of the brain and orbits. MAIN OUTCOME MEASURES: Optic nerve status, visual field status, and visual acuity. RESULTS: A subject with previously healthy optic nerves had bilateral optic neuropathy develop after LASIK surgery. This neuropathy manifested with a subjective decrease in visual field, normal visual acuity, normal color vision, relative afferent pupillary defect, increased cupping of the optic nerve with focal neuroretinal rim defects, decreased nerve fiber layer thickness, and nerve fiber bundle-type visual field defects. The subject had no other risk factors for optic neuropathy. No other cause of neuropathy was identified. CONCLUSIONS: Optic neuropathy is a potential vision-threatening complication of LASIK surgery. This complication may be due to barotrauma or ischemia related to extreme elevation of intraocular pressure by the suction ring. Careful examination of the optic nerve before and after LASIK surgery is warranted.     

Optic neuritis in children with poor recovery of vision.

We reviewed the records of 10 children with optic neuritis in whom recovery of vision was poor or incomplete. Our cases were otherwise similar to those described in previous studies in that they were always bilateral, often accompanied by a viral prodrome (seven of 10), and usually associated with disc oedema (seven of 10). Seven of twenty eyes had a final visual acuity of 6/60 or worse and only one patient regained 6/6 vision in either eye. In three patients the best vision in either eye was 6/60 or worse. Recovery of vision was often slow, taking up to six years. Five of 10 patients have developed multiple sclerosis (MS), and one child had acute disseminated encephalomyelitis (ADEM) with optic neuritis. Optic neuritis in children does not always carry a good prognosis for recovery of vision; however, the failure of vision recovery in a short period of time does not necessarily indicate a poor outcome. Some children with optic neuritis develop MS, which can develop even when optic neuritis follows a viral illness.     

Toxic optic neuropathy due to cisplatin therapy: a case report

BACKGROUND: Optic neuropathies presenting as bilateral disc oedema lead to a vast field of differential diagnosis; a toxic aetiology should be taken into consideration. HISTORY AND SIGNS: A 55-year-old patient with a non-metastatic pleuramesothelioma received cisplatin as palliative chemotherapy. Due to a unilateral high myopia on the left eye the patient has a severe anisometropic amblyopia. The patient complained about visual loss and changed colour vision. Visual acuity was 0.1 on the right eye and counting fingers on the left eye. The anterior parts of the eyes were unremarkable, the optic nerve head showed bilateral disc oedema. The MRI was free of tumour or signs of elevated intracranial pressure. Colour vision test Panel D-15 revealed a pathologic colour perception affecting the tetartan-axis. Perimetry showed a cecocentral and superior bundle scotoma. THERAPY AND OUTCOME: The patient has been treated with methylprednisolone (Solu-Medrol) 500 mg i. v. 1 gr daily for three days, continued by 100 mg oral steroids successively reduced over a period of three weeks. After three weeks visual acuity increased to 0.3. CONCLUSIONS: Toxic neuropathies including disc oedema, retinal oedema and optic neuritis are rare, but have been described as occasional side effects of treatment with cisplatin.     

A case of bilateral uveitis and optic disc swelling with Chiari I malformation

We report a case of bilateral uveitis and optic disc swelling with Chiari I malformation. A 16-year-old girl was admitted to our clinic due to conjunctival hyperaemia and blurred vision in her right eye. Ophthalmologic and systemic examinations were performed. Visual acuity was 0.7 (OD) and 1.0 (OS). Bilateral optic disc swelling was observed. Fluorescein angiography demonstrated bilateral retinal vasculitis as well as optic disc hyperflourescence due to leakage. Laboratory examinations were within normal limits. Cranial magnetic resonance venography imaging revealed neither cranial mass nor cerebral venous thrombosis but a Chiari I malformation. The patient was started oral cetazolamid, topical and oral corticosteroids. After six months follow-up, bilateral optic disc swelling was resolved completely and visual acuity was 1.0 in both eyes. Optic disc swelling may be associated with intraocular inflammation; however, patients with bilateral optic disc swelling should be suspected of having an accompanying intracranial pathology.