visual pathway disorders
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Amr Hassan, MD, FEBN Associate professor of Neurology - Cairo University
Visual Pathway
Disorders
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Optic nerve
2
• Anatomy of visual pathway
• Visual pathway disorders
• Quiz
• How to examine
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Optic nerve
3
• Anatomy of visual pathway
• Visual pathway disorders
• Quiz
• How to examine
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Optic nerve
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Pathway extends from the
„front‟ to the „back‟ of the
brain.
The Visual Pathway
OT
ON OC
VISUAL CORTEX
RETINA
VISUAL FIELD
LGN
OPTIC RADIATIONS
ON = Optic Nerve
OC = Optic Chiasm
OT = Optic Tract
LGN = Lateral Geniculate Nucleus of Thalamus
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The Visual Pathway
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Eyes & Retina
Light >> lens >> retina (inverted and reversed image).
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Eyes & Retina
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• Macula: oval region approximately 3-5 mm that surrounds the fovea, also has high visual acuity.
• Fovea: central fixation point of each eye// region of the retina with highest visual acuity.
Eyes & Retina
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Eyes & Retina
• Optic disc: region where axons leaving the retina gather to form the Optic nerve.
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Eyes & Retina
• Blind spot located 15° lateral and inferior to central fixation point of each eye.
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Object to be seen
Peripheral Retina
Central Retina (fovea in the macula lutea)
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© Stephen E. Palmer, 2002
Photoreceptors
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© Stephen E. Palmer, 2002
Cones • Cone-shaped • Less sensitive • Operate in high light • Color vision • Less numerous • Highly represented in the
fovea >> have high spatial & temporal resolution >> they detect colors.
Photoreceptors
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© Stephen E. Palmer, 2002
Rods • Rod-shaped • Highly sensitive • Operate at night • Gray-scale vision • More numerous than cons-
20:1, have poor spatial & temporal resolution of visual stimuli, do not detect colors >> vision in low level lighting conditions
Photoreceptors
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Retina up-close
Light
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Rods and Cones (Receptors)
Ganglion cells axons form the optic nerve
Bipolar cells
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Photoreceptors
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Photoreceptors
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Form Eye to the CNS
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• Different names for primary visual cortex:
• Brodmann’s area 17
• V1
• primary visual cortex
• striate cortex (“striped” cortex)
Visual Cortex – Primary Visual
Cortex
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Retinal Topography
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Visual Cortex
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• Cells in area MT or V5 respond to movement but not color
• For example, this particular neuron in this monkey’s V5 area responds best when stimulus moved down and to the left
Visual Cortex: Area MT or V5
MOTION
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Visual Cortex:Area V4
COLOUR
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Visual Cortex
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Optic nerve
28
• Anatomy of visual pathway
• Visual pathway disorders
• Quiz
• How to examine
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Optic nerve
29
• Anatomy of visual pathway
• Visual pathway disorders
• Quiz
• How to examine
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• Visual acuity
• Colour vision
• Visual field
• Fundus examination
How to examine
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Visual acuity
Snellen chart • Counting fingers 6 meters to
30 cm. • Hand movement. • Perception of light.
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• Ishihara colour plates
Colour vision
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Fundus examination • NORMAL FUNDUS
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• Confrontation method
Field examination
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Field examination
Automated perimetry Bjerrum screen.
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Optic nerve
37
• Anatomy of visual pathway
• Visual pathway disorders
• Quiz
• How to examine
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Optic nerve
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• Anatomy of visual pathway
• Visual pathway disorders
• Quiz
• How to examine
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PAPILLODEMA
• Normal
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Retinitis Pigmentosa
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Visual field defect
Dyschromatopsia
Abnormal papillary response
± Diminution/loss of vision
Optic Neuritis : Common presentation
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An Egyptian Patient
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Blood supply of the optic nerve
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PARAMETER FINDING
Visual Acuity Often better than 20/100.
Visual Field Typically Inferior Altitudinal defect.
Colour Vision May be severely impaired when VA is good.
Ophthalmic Exam Findings Diffuse OR sectorial hyperaemic disc swelling associated with FEW peripapillary splinter-shaped haemorrhages.
Small OR cupless disc in fellow eye.
Swelling gradually resolves and pallor in 3-6 weeks after onset.
FA Finding Acute Stage: localized disc hyperfluorescence, intense, eventually involves entire disc.
Laboratory Evaluation No associated laboratory abnormalities.
Ischemic Optic Neuropathy:NAION
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<40 >50 Age
92%+ Unusual pain
APD+ APD+ Pupil
Central Altitudinal VF
Edema 33% hyperemic Edema 100% pale Optic disk
Unusual Common Retinal Hge
No delayed Delayed disk filling F.A.
enhancement No optic nereve
enhancement
MRI
NAION Optic neurtis
Ischemic Optic Neuropathy:NAION
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Symptoms: • Acute vision loss one or both eyes
• Painless
Signs: • VF loss
• RAPD +ve
• Swollen Optic Disc (AION) + flame haemorhage
Ischemic Optic Neuropathy: AAION
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Ischemic Optic Neuropathy: AAION
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Fundus photographs of right eye with A-AION: (A) Before developing A-AION (B) One week after developing A-
AION with chalky white optic disc edema and
(C) 4 months later showing optic disc cupping with a cup/disc ratio of 0.8 (note no cup in A)
Hayreh SS (2009) Ischemic optic neuropathy. Progress in retinal and eye research 28: 34-62
Ischemic Optic Neuropathy: AAION
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WORK UP: FFA finding
Fundus photograph (A) and fluorescein fundus angiogram (B) of right eye with A-AION and cilioretinal artery occlusion during the initial stages. (A) Fundus photograph shows chalky white optic disc edema with retinal infarct in the distribution of occluded cilioretinal artery. (B) Fluorescein fundus angiogram shows evidence of occlusion of the medial posterior ciliary artery and no filling of the cilioretinal artery.
Hayreh SS (2009) Ischemic optic neuropathy. Progress in retinal and eye research 28: 34-62
Ischemic Optic Neuropathy: AAION
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Pale optic disc edema with adjacent retina infarcted
Chalky white pale,swollen and hyperemic optic disc
Ischemic Optic Neuropathy: AAION
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Visual field defect (Altitudinal & inferiorly)
Ischemic Optic Neuropathy: AAION
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Hereditary Optic Neuropathy: AD (Kjers’ type)
• The optic disc : temporal pallor and in some cases severe
excavation and cupping.
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Hereditary Optic Neuropathy: LHON
• Visual filed defects tend to be central or cecocentral as
the papillo-macular bundle is first and most severely
affected
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Hereditary Optic Neuropathy: LHON
• Fundoscopy may show disk swelling, thickening of the
peripapillary retinal nerve fiber layer
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Monocular blindness
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Bitemporal hemianopia
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Contralateral homonymous hemianopia
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Optic nerve-type field defects
• Retinal fibers enter optic discs in a specific manner.
• Nerve fiber bundle (NFB) defects are of the following:
1. Papillomacular bundle.
2. Sup. & Inf. Arcuate bundle.
3. Nasal bundle.
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Papillomacular Bundle
• Macular fibers that enter the temporal aspect of the disc.
• Defect, result in the following:
1. Central scotoma: defect covering central fixation.
2. Centrocecal scotoma: a central scotoma conneted to the blind spot.
3. Paracentral scotoma: defect of some of the fibers of the papillomacular bundle lying next to, but not involving central fixation.
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Papillomacular bundle-defects
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Lesions of the Visual Pathway 1. Normal visual fields
2. Blindness of the right eye
3. Blindness of right eye + contralateral left upper
quadrantanopia
4. Bitemporal heteronymous hemianopsia
5. Left homonymous hemianopsia
6. Left upper homonymous quadrantanopsia
7. Left homonymous hemianopsia with macular
sparing
Right Left
Definitions
Strabismus
Diplopia
Amblyopia
Scotoma
Quadrantanopsia - # 3, 6
Hemianopsia - # 4, 5, 7
Heteronymous Defects - # 3, 4
Homonymous Defects - # 5, 6, 7
Congruous Defects - # 5, 6, 7
Incongruous Defects - # 3
Altitudinal Defects - # 6
Masked area = area
of visual loss
Aka
“field
cuts”
Fields, not
retinal
quadrants
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Lesions of the Visual Pathway 1. Normal visual fields
2. Blindness of the right eye
3. Blindness of right eye + contralateral left upper
quadrantanopia
4. Bitemporal heteronymous hemianopsia
5. Left homonymous hemianopsia
6. Left upper homonymous quadrantanopsia
7. Left homonymous hemianopsia with macular
sparing
Right Left
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• Hemianopia – loss of pattern vision in either the left or right visual field
• Quadrantanopia –blindness in one quadrant of the visual field – damage to the optic tract, LGN or V1
Lesions of the Visual Pathway
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Deficits in Motion Perception:
Akinetopsia
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Deficits in Color Perception -
Achromatopsia
• Congenital colorblindness (dichromats) vs. acquired colorblindness
• Usually associated with damage to V4 • Object recognition OK
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Deficits in Color Perception -
Achromatopsia
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Deficits Following Damage to the
WHAT Pathway
• Visual agnosia – partial or total inability to recognize visual stimuli, unexplainable by a defect in elementary sensation or reduced level of alertness or memory
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Optic nerve
74
• Anatomy of visual pathway
• Visual pathway disorders
• Quiz
• How to examine
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Optic nerve
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• Anatomy of visual pathway
• Visual pathway disorders
• Quiz
• How to examine
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Describe the visual field defect ?
1
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Describe the visual field defect ?
2
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Describe the visual field defect ?
3
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Describe the visual field defect ?
4
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Describe the visual field defect ?
5
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Describe the visual field defect ?
6
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Describe the visual field defect ?
7
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Describe the visual field defect ?
8
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Describe the visual field defect ?
9
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Describe the visual field defect ?
10
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Describe the visual field defect ?
11
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Bitemporal Homonymous Hemianopia
Describe the visual field defect ?
1
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Describe the visual field defect ?
2 Left Homonymous Hemianopia
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Right superior quadrantanopia >>
temoporal lobe lesion
Describe the visual field defect ?
3
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Left inferior quadrantanopia >> parietal
lobe lesion
Describe the visual field defect ?
4
![Page 91: Visual Pathway Disorders](https://reader030.vdocuments.us/reader030/viewer/2022012607/619b6f5b5d13d71173129b64/html5/thumbnails/91.jpg)
Describe the visual field defect ?
5 Right homonymous hemianopia
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Left homonymous hemianopia with
macular sparing
Describe the visual field defect ?
6
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Left incongruous homonymous hemianopia
Describe the visual field defect ?
7
![Page 94: Visual Pathway Disorders](https://reader030.vdocuments.us/reader030/viewer/2022012607/619b6f5b5d13d71173129b64/html5/thumbnails/94.jpg)
Enlarged Blind Spot
Describe the visual field defect ?
8
![Page 95: Visual Pathway Disorders](https://reader030.vdocuments.us/reader030/viewer/2022012607/619b6f5b5d13d71173129b64/html5/thumbnails/95.jpg)
Describe the visual field defect ?
Junctional scotoma: lesion at junction of
optic nerve and chiasm
9
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Left sector sparing homonymous
hemianopia >> lesion at LGN.
Describe the visual field defect ?
10
![Page 97: Visual Pathway Disorders](https://reader030.vdocuments.us/reader030/viewer/2022012607/619b6f5b5d13d71173129b64/html5/thumbnails/97.jpg)
Describe the visual field defect ?
11
A. B.
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Describe the visual field defect ?
11
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THANK YOU [email protected]