Diameter of the optic nerve in idiopathic optic neuritis and in anterior ischemic optic neuropathy

Purpose: There is considerable overlap in the clinical profile of patients with idiopathic optic neuritis(ON) and anterior ischemic optic neuropathy (AION). We tested the hypothesis that the retrobulbar diameter of the optic nerve may be a criterion for the differential diagnosis between ON and AION. Methods: The diameter of the optic nerve was measured by B-scan ultrasonography with the eye in an abducted position. Only patients with a unilateral optic neuropathy were included, 16 ON patients (mean age 24years, 5 with and 11 without disc swelling) and 9patients with AION (mean age 72 years). As controls for the ON patients 10 young normal subjects (mean age25 years) and as controls for the AION patients 10elderly subjects with eye problems not related to the optic nerve (mean age 76 years) were examined. Results: In the ON patients with disc swelling the diameter of the optic nerve was 5.4 ± 0.5 mm in the affected and 3.0 ± 0.3 mm in the unaffected side. This difference was significant (Wilcoxon-test, p = 0.043). In the ON patients without disc swelling the diameter of the optic nerve was 4.4 ± 0.4 mm in the affected and 3.0 ± 0.3 mm in the unaffected side. This difference was significant (Wilcoxon-test, p = 0.003). In the AION patients the diameter of the optic nerve was 3.0 ± 0.3 mm on the affected and2.8 ± 0.4 mm on the unaffected side. This difference was not significant (Wilcoxon-test, p =0.093). Comparing the optic nerves with ON and AION to those of the controls, the diameter was significantly enlarged in the nerves with ON and normal in the nerves with AION (one factor repeated ANOVA). Conclusion: The diameter of the optic nerve is increased in ON without disc swelling and even more so in ON with disc swelling. The enlargement is probably due to edema of the nerve itself, not the surrounding subarachnoidal space. In AION, the diameter of the optic nerve is normal. Measuring the diameter of the optic nerve by B-scan ultrasonography is particularly useful in the differential diagnosis between ON with disc swelling and AION. This revised version was published online in August 2006 with corrections to the Cover Date.     

视神经周围炎的研究进展

视神经周围炎(OPN)是指涉及视神经鞘膜的一系列病理性炎症.OPN的经典三联征包括单侧视神经病变伴随疼痛和/或视盘水肿,此病症与其它视神经病变相似,导致诊断延迟和治疗欠佳.2016年1月,我们对发表于Medline和Ovid数据库的关键词为“视神经周围炎”的各种语言的文献进行了检索,共查找到60篇文献,发表于1956-2015年.两位作者(Tai ELM和Tevaraj JMP)分别对论文摘要进行了独立筛选,并筛选出相关文章.本次综述,我们强调OPN的特点,特别是OPN和视神经炎之间的临床差异.虽然大多数OPN的病例是特发性的,但仍需进行调查以排除特异性感染和继发性OPN的炎症原因.MRI是非常重要的检查方法,由于OPN视神经周围炎症的影像学诊断.糖皮质激素治疗可使症状与体征迅速好转,长期口服糖皮质激素并慢速递减可以降低复发的风险.     

A review of optic perineuritis

Optic perineuritis (OPN) refers to a spectrum of conditions involving pathologic inflammation of the optic nerve sheath. The classic triad of OPN consists of unilateral optic neuropathy associated with pain and/or disc oedema, but the condition often mimics other optic neuropathies, resulting in delayed diagnosis and suboptimal treatment. We performed a database search of Medline and Ovid in January 2016 for articles published in any language with the keywords ‘optic perineuritis’. Sixty articles were found, published from 1956 to 2015. Two reviewers (Tai ELM and Tevaraj JMP) performed an independent screening of abstracts. Articles of interest were subsequently examined. In this review, we highlight the salient features of OPN, with particular emphasis on the clinical differences between OPN and optic neuritis. Although the majority of cases of OPN are idiopathic, investigations are required to rule out specific infectious and inflammatory causes of secondary OPN. MRI is an invaluable component of the workup, as radiographic demonstration of peri-neural inflammation is diagnostic of OPN. Corticosteroid therapy results in dramatic and rapid reversal of the signs and symptoms, but prolonged therapy with slow tapering of oral corticosteroids may be necessary to reduce the risk of relapses.     

Anterior ischaemic optic neuropathy in a patient with optic disc drusen

Background: Although visual field defects are well-known complications of optic disc drusen, reduction in visual acuity with this condition is rare. Method/Results: We report on a 68-year-old male with bilateral optic disc drusen who presented with monocular loss of vision in the right eye associated with an inferior altitudinal visual field defect and signs consistent with acute anterior ischaemic optic neuropathy, confirmed on fluorescein angiography. He also had a left inferior nasal step, but no evidence of glaucomatous cupping. The disc drusen were documented clinically and on B scan ultrasound and computed tomography. Conclusions: The diagnosis of acute anterior ischaemic optic neuropathy should be considered in patients with optic disc drusen who present with reduced visual acuity, particularly when the visual loss has been acute and non-progressive and is associated with altitudinal field loss and characteristic fluorescein angiography signs.     

Multifocal visual evoked potential in optic neuritis,ischemic optic neuropathy and compressive optic neuropathy

Purpose:

To investigate the effect of optic neuritis (ON), ischemic optic neuropathy (ION) and compressive optic neuropathy (CON) on multifocal visual evoked potential (mfVEP) amplitudes and latencies, and to compare the parameters among three optic nerve disorders.

Materials and Methods:

mfVEP was recorded for 71 eyes of controls and 48 eyes of optic nerve disorders with subgroups of optic neuritis (ON, n = 21 eyes), ischemic optic neuropathy (ION, n = 14 eyes), and compressive optic neuropathy (CON, n = 13 eyes). The size of defect in mfVEP amplitude probability plots and relative latency plots were analyzed. The pattern of the defect in amplitude probability plot was classified according to the visual field profile of optic neuritis treatment trail (ONTT).

Results:

Median of mfVEP amplitude (log SNR) averaged across 60 sectors were reduced in ON (0.17 (0.13-0.33)), ION (0.14 (0.12-0.21)) and CON (0.21 (0.14-0.30)) when compared to controls. The median mfVEP relative latencies compared to controls were significantly prolonged in ON and CON group of 10.53 (2.62-15.50) ms and 5.73 (2.67-14.14) ms respectively compared to ION group (2.06 (-4.09-13.02)). The common mfVEP amplitude defects observed in probability plots were diffuse pattern in ON, inferior altitudinal defect in ION and temporal hemianopia in CON eyes.

Conclusions:

Optic nerve disorders cause reduction in mfVEP amplitudes. The extent of delayed latency noted in ischemic optic neuropathy was significantly lesser compared to subjects with optic neuritis and compressive optic neuropathy. mfVEP amplitudes can be used to objectively assess the topography of the visual field defect.     

Toxic optic neuropathy

Toxic optic neuropathy (TON) is a disease entity which is not only underdiagnosed, but also often diagnosed at a stage when recovery of vision is not possible. This article gives an overview of common causes, clinical features, and management of TON.     

青光眼与非炎症性缺血型视神经病变的傅立叶OCT扫描视神经形态学对比

目的 比较青光眼与非炎症性缺血型视神经病变(non-arteritic ischemic optic neuropathy,NAION)患者患眼的视盘及盘周视网膜神经纤维层(peripapillary retinal nerve fiber layer,pRNFL)参数变化情况及诊断能力.方法 选择我院眼科年龄≥40岁就诊患者71例(71眼).受试者分为青光眼组26例、NAION组15例、对照组30例,排除视野缺损范围大于两个象限或等效球镜度数大于±6D的受试眼以及发病时间小于6个月的NAION患眼.所有患者均接受眼部常规检查,使用傅立叶OCT测量视盘及pRNFL各参数.结果 3组之间除视盘面积外(P =0.059),其余视盘及pRNFL各参数差异均有统计学意义(均为P＜0.05).经LSD两两比较发现:青光眼组的视杯面积(1.438±0.714)mm2最大(均为P ＜0.05),盘沿面积(0.965 ±0.652)mm2最小(均为P＜0.05),盘沿容积和视神经盘容积[(0.103 ±0.089)mm3、(0.195±0.168)mm3]最小(均为P＜0.05),视杯容积(0.482 ±0.420)mm3最大(均为P ＜0.05),杯盘比最大(均为P＜0.05);NAION组的视杯面积(0.493±0.344) mm2最小(均为P＜0.05),盘沿面积(1.255±0.294) mm2与对照组(1.243±0.509) mm2差异无统计学意义(P＞0.05),盘沿容积(0.196±0.094)mm3、视神经盘容积(0.339±0.109) mm3与对照组差异均无统计学意义(均为P＞0.05),视杯容积(0.083 ±0.073)mm3最小(均为P＜0.05),杯盘比最小(均为P＜0.05).在pRNFL方面,经LSD两两比较发现:3组在平均值及TU、ST、SN、NU、IT区之间两两比较差异均有统计学意义(均为P＜0.05);在NL、IN、TL区,青光眼组与对照组两两比较差异均有统计学意义(均为P ＜0.05).将青光眼组与对照组进行AROC分析发现:视盘参数中除视盘面积外(P＞0.05),其他参数及所有pRNFL各参数差异均有统计学意义(均为P＜0.05).将NAION组与对照组进行AROC分析发现:pRNFL中的上方(即ST、SN区)、鼻上(即NU区)和下方偏颞侧(即IT区)AROC差异均有统计学意义(均为P＜0.05),视盘所有参数及pRNFL其余部位差异均无统计学意义(均为P ＞0.05).将NAION组与青光眼组进行AROC分析发现:视盘参数中视杯面积、视杯容积、杯盘比(包括面积、水平和垂直)的AROC差异均有统计学意义(均为P＜0.05),而pRNFL中的颞上方(即TU区)、鼻上方(即NU区)和平均值AROC差异均有统计学意义(均为P＜0.05),其余部位差异均无统计学意义(均为P＞0.05).结论 通过傅立叶OCT检测可发现青光眼与NAION在视盘及pRNFL方面的差异,为理解此两种视神经疾病的发病特点及鉴别诊断提供临床依据.     

不同时期特发性脱髓鞘性视神经炎视神经扩散张量成像研究

目的探讨不同时期特发性脱髓鞘性视神经炎（IDON）患者视神经扩散张量成像（DTI）指标的变化规律。设计前瞻性病例对照研究。研究对象35例IDON患者及与患者性别、年龄相匹配的35例健康志愿者。方法应用GE1．5T磁共振扫描仪对研究对象进行视神经DTI检查,扫描时间约10分钟,利用FMRIB软件对图像进行校正和配准,利用DTIStudio软件进行视神经DTI参数的测量,分析扩散指标变化。主要指标平均扩散率（MD）、各向异性分数（FA）、最大本征值（λ∥）和横向本征值（λ⊥）。结果与对照组相比,首次受累的急性期IDON视神经DTI指标变化以FA值降低（P=0．000）和入上值升高（P=0．000）为主,缓解期IDON视神经DTI指标变化为FA值降低（P=0．000）,MD值（P=0．004）、λ∥值（P=0．005）和入上值升高（舟0．000）。结论磁共振成像DTI技术可敏感地检测特发性脱髓鞘性视神经炎患者视神经内的水弥散异常,并且视神经DTI指标能够反映不同时期组织的病理生理改变特点及其脱髓鞘程度。     

外伤性视神经病变经鼻内镜下视神经管减压及综合治疗

目的 回顾外伤性视神经病变经鼻内镜下视神经管减压合并药物治疗的结果,探讨手术适应证.设计回顾性病例系列.研究对象2006年～2010年北京同仁医院耳鼻咽喉头颈外科收治的外伤性视神经病变患者69例（69眼）.方法 患者术前均行视神经管CT检查,除外严重颅脑外伤合并症,行鼻内镜下经筛、蝶窦视神经管减压术,同时给予围手术期激素冲击、营养神经及扩张血管等综合药物治疗.主要指标手术后视力.结果 59例（85.5%）术前CT扫描显示视神经管骨折.67例（97.1%）行视神经管减压术,其中因鞘膜水肿或鞘膜下积血切开神经鞘2例 1例放弃手术 另1例视力自行恢复出院.随诊2～44个月,术后视力改善30例（44.8%）,其中从无光感到有光感18例,视力大于0.1者9例.结论 经鼻内镜视神经管减压联合药物治疗是目前治疗外伤性视神经病变的推荐方法之一,在除外手术禁忌的情况下,应积极手术并结合药物治疗,挽救视力.     

Management of ischemic optic neuropathies

Ischemic optic neuropathies (IONs) consist primarily of two types: anterior ischemic optic neuropathy (AION) and posterior ischemic optic neuropathy (PION). AION comprises arteritic AION (A-AION: due to giant cell arteritis) and non-arteritic AION (NA-AION: due to other causes). PION consists of arteritic PION (A-PION: due to giant cell arteritis), non-arteritic PION (NA-PION: due to other causes), and surgical PION (a complication of several systemic surgical procedures). These five types of ION are distinct clinical entities etiologically, pathogenetically, clinically and from the management point of view. In the management of AION, the first crucial step with patients aged 50 and over is to identify immediately whether it is arteritic or not because A-AION is an ophthalmic emergency and requires urgent treatment with high-dose steroid therapy to prevent any further visual loss in one or both eyes. Patients with NA-AION, when treated with systemic corticosteroid therapy within first 2 weeks of onset, had significantly better visual outcome than untreated ones. Systemic risk factors, particularly nocturnal arterial hypotension, play major roles in the development of NA-AION; management of them is essential in its prevention and management. NA-PION patients, when treated with high-dose systemic steroid therapy during the very early stages of the disease, showed significant improvement in visual acuity and visual fields, compared to untreated eyes. A-PION, like A-AION, requires urgent treatment with high-dose steroid therapy to prevent any further visual loss in one or both eyes. There is no satisfactory treatment for surgical PION, except to take prophylactic measures to prevent its development.     

Indirect injury to the optic nerves and optic chiasm

Abstract. Twenty-five cases of indirect injury to the optic nerve or chiasm following blunt trauma to the head were retrospectively reviewed. Falls onto the head and road traffic accidents together accounted for most (88%) of the head injuries. Bony skull fractures were identified in 23 cases (92%), although in only five of these (20%) was one of the optic canals or anterior clinoid processes involved in a fracture. Visual loss was bilateral in 11 patients (44%). In eight of these bilateral cases the visual field defects suggested a lesion at or near the optic chiasm. In one case optic nerve function deteriorated after the initial assessment. This deterioration was reversed by treatment, which consisted of surgical drainage of an orbital haematoma and systemic corticosteroids.     

兔眼放射状视神经切开术后视盘的形态学改变

目的观察兔眼放射状视神经切开术（RON）后视盘的形态学改变。方法 40只健康成年家兔随机分为正常对照组及术后1、2、4周组,每组10只兔。手术组兔眼行RON后,分别于术后1、2、4周行眼底照相,用IPP5.0软件测量视盘面积、视盘水平径和垂直径,并行常规组织病理学检查。结果所有RON手术均成功,术中未见严重玻璃体积血和视网膜脱离,仅RON手术部位有少量出血。RON术后1周组的视盘面积和垂直直径较正常组增大（P〈0.01）,术后2周组与1周组比较差异无统计学意义（P〉0.05）,术后4周组与其他组两两比较差异均有统计学意义（P〈0.01）。组织病理学检查可见,术后1周组RON手术部位可见淋巴细胞和单核细胞浸润,术后2周组和术后4周组手术部位被大量胶原成分填充。结论兔眼RON术后视盘直径和面积增大,可为RON的作用机制提供实验依据。     

Etanercept associated optic neuropathy

We report the case of a 14-year-old boy who developed optic neuropathy subsequent to the use of etanercept. There have been 15 reported cases of anti-TNF-alpha-associated optic neuropathy to date and their characteristics are reviewed in this report, as well as possible pathophysiologic mechanisms behind such phenomenon. Such cases demonstrate the importance of prompt ophthalmologic evaluation of visual changes in patients being treated with anti-TNF-alpha antagonists.     

放射性视神经病变

本文对１２例１４只眼的放射性视神经病变作了报导。并就放射性视神经病变的诊断要点作了介绍。文章认为高压氧加光量子照射自血回输是治疗放射性视神经病变的最佳治疗方法。     

Pallor of the optic disc in children

This report discusses the subject of pallor of the optic disc from the viewpoint of a paediatric neurologist. The paper is divided into two sections, one on optic atrophy in childhood and the second on optic nerve hypoplasia. Optic atrophy in children is a topic which is very poorly covered in standard textbooks either of neurology or ophthalmology. This review attempts to develop a working approach to the management of children who present with optic nerve atrophy as their primary neurological finding.     

Congenital anomalies of the optic disc

Although anomalies affecting the optic nerve head are usually clinically innocuous, they can sometimes cause significant symptoms and lead to visual loss. It is important to be able to recognize even the relatively benign lesions in order to differentiate them from other more threatening lesions or disease processes which they may clinically resemble. An awareness of the clinical appearance of disc anomalies is especially important in the differential diagnosis of optic nerve glaucomatous changes. Some anomalies cause various types of visual field loss which, if the actual disc lesion is not recognized, may lead to unnecessary neurologic evaluation or even to intracranial surgery. The optic nerve changes in acquired myopia and in the congenital tilted disc syndrome should be clearly defined and differentiated: high (pathologic) myopia may be highly progressive with many dangerous secondary sequelae, while the latter anomaly is stationary. Finally, there is a group of conditions, collectively termed “elevated anomalies of the disc,” which must be considered in the differential diagnosis of papilledema and potentially dangerous intraocular tumors, particularly retinoblastoma. This review provides a clinicopathologic correlation comparing the characteristics of the normal optic disc to those of the most important congenital anomalies of the disc.     

Diagnosis of optic nerve sheath meningioma during optic nerve sheath decompression

Optic nerve sheath meningioma (ONSM) is typically diagnosed based on clinical suspicion and imaging characteristics and is most often treated with radiation. Historically, biopsy, optic nerve sheath decompression, and debulking surgeries have been avoided for fear of optic nerve vascular disruption and tumor spread into the orbit. This is a case of a 48-year-old man who presented with unilateral optic disc edema, declining visual acuity, and a visual field defect. Despite an initial improvement with acetazolamide, his vision subsequently worsened. With an elevated lumbar puncture opening pressure and imaging showing right optic nerve sheath enhancement, the differential diagnosis included ONSM, perineuritis and idiopathic intracranial hypertension (IIH). Optic nerve sheath decompression (ONSD) with biopsy was performed, simultaneously decompressing the nerve and yielding a sample for pathologic analysis. A pathologic diagnosis of ONSM was made and treatment with radiation was subsequently initiated, but vision began to improve after the surgical decompression alone.     

微创鼻内镜下视神经减压术在外伤性视神经病患者中的应用

目的 分析鼻内镜下视神经减压术在外伤性视神经病患者中的应用效果.方法 选取2014年1月至2016年1月我院收治的外伤性视神经病患者100例(100眼)为观察对象,按治疗方法不同分为观察组与对照组,每组各50例.对照组采取药物治疗模式,观察组在对照组的基础上,待病情稳定后采取鼻内镜下视神经减压术治疗.术后至少随访1 a,对比两组患者的临床疗效、视力、视觉诱发电位检查结果、不良反应发生率等.结果 观察组与对照组的治疗有效率分别为76.0％和36.0％,两组相比差异有统计学意义(P＜0.05).观察组22眼无光感者中16眼视力提高,13眼光感者中9眼视力提高,11眼眼前手动者中9眼视力提高,4眼眼前数指者视力全部提高;对照组20眼无光感者中6眼视力提高,14眼光感者中6眼视力提高,12眼眼前手动者中5眼视力提高,4眼眼前数指者中1眼视力提高.治疗后,观察组P100潜伏期为(116.85±7.96) ms,P100振幅为(5.11±1.16)μV,均优于对照组的(105.62±6.82) ms、(4.31±1.25) μV.观察组不良反应发生率显著低于对照组(P =0.000).结论 鼻内镜下视神经减压术在外伤性视神经病患者中具有较好的应用效果和安全性,能够有效改善患者的视力,有助于提升患者的生活质量,值得在临床中推广使用.     

非动脉炎性前部缺血性视神经病变视盘形态的Meta分析

目的 采用Meta分析的方法评价非动脉炎性前部缺血性视神经病变（Nonarteritic anterior ischemic optic neuropathy,NAION）患者视盘形态特点。设计 系统综述。研究对象 检索万方全文数据库、EMBASE和Pubmed 数据库中有关NAION 患者视盘定量测量的临床研究文献。方法 依据纳入和排除标准筛选文献,对纳入的研究进行数据提取并进行meta分析,统计学采用Stata软件进行异质性检验、合并WMD和敏感性分析。主要指标 视盘形态学参数。结果 共7篇文献符合纳入标准。NAION患者对侧健眼与正常对照比较,视盘面积（WMD=-0.20,95%CI：-0.37~-0.03）、视杯面积（WMD=-0.36,95%CI：-0.58~-0.14）、杯盘面积比（WMD=-0.15,95%CI：-0.23~-0.06）、视杯容积（WMD=-0.08,95%CI：-0.12~-0.05）、平均视杯深度（WMD=-0.10,95%CI：-0.13~-0.06）、视杯形态测量（WMD=-0.03,95%CI：-0.05~-0.02）均小于正常对照组,差异有统计学意义;而盘沿面积（WMD=0.05,95%CI：-0.15~0.25）、盘沿容积（WMD=0.05,95%CI：-0.07~0.16）两组间差异无统计学意义。NAION患者患眼与对侧健眼比较,盘沿容积（WMD=-0.08,95%CI：-0.14~-0.02）较健眼小,视杯形态测量（WMD=0.03,95%CI：0.00~0.06）较健眼大,差异有统计学意义;视盘面积（WMD=0.08,95%CI：-0.04~0.19）、视杯面积（WMD=0.08,95%CI：-0.01~0.17）、盘沿面积（WMD=-0.05,95%CI：-0.17~0.08）、杯盘面积比（WMD=0.02,95%CI：-0.02~0.06）、视杯容积（WMD=0.01,95%CI：-0.02~0.03）、平均视杯深度（WMD=0.00,95%CI：-0.02~0.03）差异两组间无统计学意义。结论NAION患者具有小视盘、小视杯的特点;NAION发生后,视杯有扩大趋势。（眼科,2014, 23： 235-239）     

Absence of age-related optic disk changes in young children with optic nerve hypoplasia

Purpose

To determine whether the ratio of optic disk diameter to disk-to-macula distance (DD/DM) in children with optic nerve hypoplasia (ONH) changes over time.

Patients and methods

Fifteen subjects (29 eyes) enrolled in a prospective registry study on ONH had fundus photography performed under the age of 24 months and again at 60 months. Using the ratio of the DD/DM method, the relative size of the optic disk was assessed twice for each photo by one masked expert examiner to determine whether any change in relative disk size occurred over time.

Results

There was no change in relative optic disk size between initial and final fundus photographs. The average (±SD) age at the time of initial and final fundus photography was, respectively, 11.6±5.2 months and 60.6±1.3 months. Strong concordance was noted between the average DD/DM of the initial and the final photographs (ρ=0.939; 95% CI: 0.893, 0.981). There was negligible difference between the individual time point measurements (−0.011±0.03) (95% LOA: −0.07, 0.04).

Conclusion

There were no clinically significant changes in relative optic disk size over time in children with ONH; thus, DD/DM measurements need not be adjusted by age beyond 1 year in children with this disorder.