Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.

Approach to a pale optic disc

A systematic approach with practical tips to diagnose and manage optic disc pallor. Disc pallor is often encountered in the routine clinical practice and remains a diagnostic enigma for most ophthalmologist. I illustrate the relevant practical points to be looked out for to deal with disc pallor.

  • Identifiez-vous pour voir les commentaires

Approach to a pale optic disc

  1. 1. APPROACH TO A PALE OPTIC DISC
  2. 2. OVERVIEW • INTRODUCTION • IMPORTANT POINTS IN HISTORY • IMPORTANT POINTS IN EXAMINATION • RELEVANT INVESTIGATIONS • MANAGEMENT • CASE EXAMPLE
  3. 3. • Rule out the mimics • Clinical diagnosis • Classify – Pattern of optic disc appearance – Etiology • Investigations to confirm diagnosis • Assess visual prognosis (progressive / static) • Management (if needed)
  4. 4. INTRODUCTION • End result of a number of pathologic processes leading to loss of axonal fibres and their replacement by glial tissue • Normal color is salmon pink – Vascularity – Proportional glial and axonal elements
  5. 5. • Pale appearance due to – Decreased vascularity – Capillary dropout – Gliosis – Increased visibility of scleral laminae
  6. 6. AIM OF CLINICAL EVALUATION • To determine the possible cause of the disc pallor and whether this is due to – An ongoing process which is likely to progress • Ischemic / compressive – Result of a previous one time insult • Inflammatory / toxic / traumatic • Visual prognosis • Any intervention needed at present
  7. 7. DIFFERENTIAL DIAGNOSIS • Optic atrophy • Disc coloboma • Optic pit • Morning glory syndrome • Medullated nerve fibres • Myopic disc • Optic disc drusen • Optic disc hypoplasia Should be kept in mind while looking at a pale disc
  8. 8. Morning glory disc Optic disc drusen Medullated nerve fibres Optic disc pit Optic disc hypoplasia Myopic disc Optic disc coloboma Optic disc pit
  9. 9. PATTERNS • Ischemic (anterior ischemic optic neuropathy) • Inflammatory • Toxic/ nutritional • Compressive • Traumatic • Hereditary
  10. 10. • Main complain is usually a decrease in visual acuity • Observant patients will tell about color desaturation and field defects
  11. 11. IMPORTANT POINTS TO ELICIT IN THE HISTORY • Unilateral or bilateral • Children / young adults / elderly population • Acute sudden loss / gradual diminution • Precipitating factors (fever / trauma / neurologic symptoms) • Associated symptoms – Jaw claudication / scalp tenderness / headache – Proptosis – Diplopia
  12. 12. • Exposure to – Drugs (ethambutol / isoniazid / chloroquine / amiodarone) – Toxins (alcohol / methanol /tobacco) – Radiation • Possibility of malnourishment • Systemic illness – Atherosclerosis – Hypertension – Diabetes mellitus – Sleep apnea – Thyroid disorder • Symptoms of B12 deficiency • Family history
  13. 13. IMPORTANT EXAMINATION POINTS • GENERAL PHYSICAL – Pallor – Pulse • Rate / rhythm / volume / symmetrical – Blood pressure (both arms) – Bruit at common carotid (upper border of thyroid cartilage) – Signs of nutritional deficiency / chronic alcohol use / chronic smoking – Gait (tunnel vision / ataxia)
  14. 14. • Best corrected visual acuity • Color vision / saturation • Pupillary reaction / RAPD • Squint / ocular movements / nystagmus • Proptosis • Confrontation fields
  15. 15. • Anterior segment – Neovascularisation of iris / angle • Ocular ischemic syndrome • IOP • Optic disc appearance – Pallor : • Diffuse • Sectoral (wedge shaped / temporal / altitudinal/ bow tie) – Patterns • Primary • Secondary • Consecutive • Glaucomatous
  16. 16. TEMPORAL PALLOR • Carries papillomacular bundle • Most active fibres with high metabolic activity • Travel through the centre of the optic nerve – Others report them being scattered throughout the nerve • Vulnerable to ischemic insult
  17. 17. • Margins • Neruroretinal rim (color / thickness) • Cupping • Lamina cribrosa visibility • Nerve fibre layer defects – Diffuse – Localised • Wedge shaped • Papillomacular bundle • Kestenbaum number
  18. 18. • Surrounding retina – Retinitis pigmentosa – DR / hypertensive changes / hemorrhages – Vascular sheathing / attenuation / dilatation – Vascular occlusion – Venous pulsations – Opticociliary shunt vessels – Signs of trauma • Choroidal rupture • Berlin’s edema Development of Opticociliary shunt vessel
  19. 19. FEATURE PRIMARY SECONDARY CONSECUTIVE APPEARANCE Chalky white Dirty grey white Waxy pallor MARGINS Well defined Ill defined Well defined LAMINA CRIBROSA Well seen Obscured Well seen VESSELS Normal Peripapillary sheathing Attenuation SURROUNDING RETINA Healthy Hyaline bodies / drusen Pathology seen
  20. 20. INVESTIGATIONS • Blood investigations – Hemogram – ESR / CRP – Liver and kidney function – Lipid profile – Blood sugar – Thyroid profile – Nutritional indicators – Hypercoagulale states • Other investigations – Carotid Doppler – Postural hypotension – Temporal artery biopsy
  21. 21. • SARCOID • COLLAGEN VASCULAR DISEASE • HEAVY METAL screen • LHON mutation screen • VISUAL FIELD • IMAGING – MRI BRAIN plus ORBIT • Suspected chiasmal compression • Suspected compressive neuropathy – CECT ORBIT • Suspected traumatic neuropathy – USG ORBIT • Suspected compressive neuropathy
  22. 22. VISUAL FIELDS Altitudinal field defect Centrocaecal scotoma Bitemporal hemianopia
  23. 23. MANAGEMENT • Irreversible loss of acuity / field • ISCHEMIC : – Hypercholesterolemia – Low dose aspirin – Vascular surgery – Pentoxifylline – Steroids in acute stage (not recommended)
  24. 24. • INFLAMMATORY – Immunosuppressants – Prognosticate for MS • COMPRESSIVE – According to the lesion – Thyroid • TRAUMATIC – Pale disc is indicator of irreversible damage • TOXIC / NUTRITIONAL – Avoid exposure – Vitamin supplementation
  25. 25. CASE • 35-year-old man with diabetes (5 yrs ; on insulin) • 2 months of blurred vision in his left eye with near work • No ocular history and never used spectacles • No family history • No history of trauma • Non smoker / alcohol user Ocular Surgery News U.S. Edition, September 15, 2007 Isabel M. Balderas, MD; Thomas R. Hedges, MD
  26. 26. • Vision (best corrected) – Right 6/6 left 6/60 – No anisometropia • Impaired color vision left eye • Anterior segment normal • Circumpapillary telangiectatic vessels • No evidence of DR
  27. 27. • MRI BRAIN : normal study • NUTRITIONAL INIDCES : normal • Suspected LHON • 11778 glycine to alanine mutation DISC PALLOR IS NOT TO BE IGNORED
  28. 28. THANK YOU

×