penyakit saraf optik
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Yunita Sp.M
(Neuro-ophthalmology division)
Penyakit saraf optik
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Saraf optik intraokular, intraorbital,
intrakanalikular dan intrakranial
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Penyakit pada saraf optik
Neuropati optik
Papiledema
Atrofi papil
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Neuropati optik
Tipikal Idiopatik
Berhubungan dengan MS
Atipikal
Infeksius Imun
Sarcoidosis
Neuropati optik non-inflamasi
ION Kompresif
Infiltratif, dsb
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Neuritis optik tipikal
Idiopatik atau berhubungan dengan MS
visus monokuler akut disertai nyeri periokular (92%)
Umur 15-45 tahun, F > M
VA 20/20NLP RAPD (+)
Diskus optik tampak normal, edema pada 1/3 kasus.
Visus < dalam 1 Minggu, membaik di minggu 2 hingga 1
tahun.
MRI ~ multifokal demielinisasi ~ MS
VEP bila terdapat tanda klinis (RAPD)
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Neuritis optik tipikal
Penanganan neuritis optik tipikal
Metil prednisolon IV 1 g/hari ~3 hari, dilanjutkan prednison
oral 1 mg/kgBB selama 11 hari
MRI
Interferon beta 1a
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Neuritis optik atipikal
Neuritis optik yang berhubungan dengan uveitis maupuninflamasi atau infeksi sitemik
Diagnosis :
Tanda klinis yang berbeda dengan neuritis optik tipikal atau
hasil hasil neuroimaging yang berhubungan dengan penyakit
selain MS.
Terbagi atas :
Infeksius
Imunologis
Sarcoidal
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a | Optic nerve head in demyelinating
optic neuritis, showing nonspecific optic
disc swelling without hemorrhages or
exudates. b | A case of infective neuroretinitis,
showing disc swelling with hemorrhages
and macular exudates, also known as a
macular star (arrow).
c | Viral optic neuritis with globalnonspecific optic disc swelling.
d | Syphilitic opticneuritis with optic
nerve head swelling, hyperemia and
hemorrhages.
e | Optic nerve head in HIV-associatedoptic neuritis, showing massive swelling
with extensive exudates and hemorrhages.
f | Toxocara-associated optic neuropathy,
with infiltration, swelling and massive
distortion of normal optic nerve head
anatomy.
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Neuropati non inflamasi
Ischemic optic neuropathy Anterior (AION)
Arteritik (AAION)
Non-arteritik (NAAION)
Posterior (PION)
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Characteristic AION NAION
Age Mean, 70 Years Mean, 60 Years
Sex F > M F = M
Associated Symptoms
Headache, scalp tenderness,
jaw claudication, transient
visual lost
Usually none
Visual acuityUsually severe (20/200
in > 60% cases)
DiscPale swelling common cup
normalPale or hyperemic, cup small
ESR Mean, 70 mm/hr Mean 20-40 mm/hrFFA Disc delay and choroid delay Disk delay
Natural historyRarely improve, fellow eye,
54%-95%
16%-42,7% improve, fellow
eye, 12%-19%
Treatment Systemic steroids None proven
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Arteritik- AION
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Gambaran fundus NAION
Gambaran FFA NAION
Non-Arteritik- AION
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Neuropati non inflamasi
Compressive opticneuropathy
Monokular/binokular
Kronik
Papil normalpucat (jarangudem)
MRI ~ massa
Defek lap pandang : nerve
fiber bundle; kadanghemianopia (massaintrakranial pada khiasma)
Massa intraorbita ~ proptosis
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Neuropati non inflamasi
Infiltrative optic neuropathy Berhubungan dengan limfoma, leukemia, plasmasitoma, atau
karsinoma
Akut-subakut
Nyeri (-)
Monokular
Papil normal-udem
MRI ~ nervus optik dan menings yang membesar.
Steroid responsif
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Neuropati non inflamasi
Radiation optic neuropathy Toksik pada saraf optik maupun retina akibat pemberian terapi
radiasi (mis pada KNF)
Radiasi > 6000 cGy
Akut
Papil normal
Monokular kadang binokular
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Neuropati non inflamasi
Hereditary optic neuropathy Defek di DNA nuklear
Dominan / resesif
Binokular
Kronik Tritan axis color blindness
Papil optik :wedge shaped temporalpallor
RAPD (-) Defek lap pandang sentral-
secosentral (dominan)
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Neuropati non inflamasi
Leber Hereditary opticneuropathy
Kelainan DNA mitokondrial
Monikularbinokolar
(minggu-bulan)
Akut - subakut
RAPD (+)
Defek lap pandang sentral-
sekosentral
Diagnosis ~ pem. Darah
mutasi
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Neuropati non inflamasi
Toxic optic neuropathy Methanol
Ethambutol
Isoniazid
Tobacco & alkohol
Pada dua mata
Akut-subakut-kronik
Defek lap pandang sentral-sekosentral
Diskromatopsia
Th/ menghilangkan sumber toksik
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Neuropati non inflamasi
Nutritional deficiency optic neuropathy Defisiensi vit B, khususnya B12
Binokular
Diskromatopsia
Defek lap pandang sentral-sekosentral
Diagnosis : eliminasi penyebab penurunan visus bilateral dan def
lap. pandang sentral-sekosentral
Th/ thiamin 50 mg/hari, multivitamin, sianokobalamin. Stop
merokok dan konsumsi alkohol
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Neuropati non inflamasi
Traumatic optic neuropathy 0,5-5% pada trauma kepala Prekanalikular
Avulsi/evulsi
Visus hilang pada saat trauma
Papil ~ lubang abu2 dikelilingihematom
Trauma 1 cm di belakang bola mata ~CRAO
Trauma > 1 cm ~ papil normal
Kanalikular
Kontusi melalui frontal Nekrosis iskemikkompresi kanal
Th/steroid dosis tinggi, dekompresikanal
O ti di h
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Optic disc changes
Retrobulbar neuritisEarly compression
Normal
Papilloedema
Papillitis and neuroretinitis
Swelling
Optic nerve sheath meningioma
Occasionally optic nerve glioma
Optico-ciliaryshunts
Postneuritic Compression
Atrophy AION
Hereditary optic atrophies
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Papilloedema
It is a passive, non inflammatory edema of the optic disc due mostly
to raised intracranial pressure. Most of cases are bilateral.
Etiology :
a. Rise of intra cranial pressure due to any space-occupying lesion
of the cranium, such as brain tumor, cerebral abscess, brain haematoma
b. Local orbital causes .. Unilateral papilloedema
c. Certain general diseases, such as malignant hipertention, nephritis,
leukemia.
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Clinical features :
Symptoms, are often negligible
- Transient blurring of sight lasting from 5-20 seconds- Normal visual acuity for several months, but failure of sight with associated
with secondary optic atrophy.
Sign,
-Hyperemic optic disc with retinal vein engorgement at initial stage
-At progressive conditions, blurred of the disc margin appear.-In the later stage, swelling of optic disc, 2-8i dioptres
-Flamed shape haemorrhages and soft exudate around the disc.
-Exudate of the macula ----- macular star.
-Field changes : blind spot (earlier), central scotoma (macular involvement),
concentric visual field (optic atrophy)
Course
A short period of oedema ---- little or no permanent change.
Several weeks or month durations ------ secondary optic atrophy ---- blindness
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Differential diagnosis: papillitis
Papillitis
-Disc swellings 2 D
-Venous engorgmenet and
retinal haemorrhages +++
-Loss of sight sudden and profound
-Transient and recovery 1-2 weeks
-Field defect central scotoma for redand green color
Papilloedema
-Disc swelling 6D-Venous engorgmenet and
retinal haemorrhages+
-Visual loss negligible and gradual
- Blindness in untreated patients
-Field defect concentric contractrion
of the peripheral field
Treatment
Remove the underlying causes (intracranial)
-Tumorremove with surgical intervention
-Abcess- drainage
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Primary Papil Atrophy
Causes:
-Following retrobulbar neuritis
-Compression by tumours or
aneurysm
-Hereditary optic neuropathy
-Toxic and nutritional opticneuropathy
-Visual pathway lesion
(retrolaminar ON to LGB)
Flat, clear delienated
margin
No antecedent ONHswelling
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Secondary Papil Atrophy
Preceded by ONH swelling
White/dirty grey
Slightly raised
Poorly delienated margin
Causes:
-Chronic papilloedema
-AION-Papilitis
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