LECTURE No. 22. Diagnosis, clinic and treatment of pathologies of the optic nerve

1. General diagnostic questions

If the patient complains of a deterioration in visual acuity, changes in the field of vision, a violation of color perception, these are signs of a pathology of the optic nerve. In such cases, it is necessary to check visual acuity, the field of view for white, red and especially green colors, to do a campimetric study, to check color perception according to Rabkin's tables.

Depending on the nature of the damage to the optic nerve, visual functions change to some extent, the blind spot increases, color perception and dark adaptation are disturbed. The optic disc may be enlarged, hyperemic or pale, its color, shape and borders are changed, prominence into the vitreous body or excavation is noted. The combination of certain signs may give rise to a diagnosis of neuritis, stagnation or atrophy of the optic nerve.

In the diagnosis of diseases of the optic nerve, a decisive role belongs to functional studies, which also make it possible to judge the dynamics of the process. In addition to functional studies, X-ray of the skull, lumbar puncture, consultations of a neuropathologist, otolaryngologist and other specialists are of great help. For effective treatment, it is important to establish an etiological diagnosis, to find out the cause of the disease.

2. Neuritis of the optic nerve (neuritus nervi optici)

The most common causes of optic neuritis in children are infectious diseases, arachnoiditis, sinusitis, multiple sclerosis, etc. Lesions of the optic nerve are observed in the intraocular part of it (papillitis), behind the eye (retrobulbar neuritis) and in the intracranial region (opticochiasmatic arachnoiditis).

With papillitis, patients complain of a rapid drop in visual acuity, which is also established during the examination. Disturbances in color perception, changes in the field of vision, an increase in the blind spot are determined, and in the fundus there is hyperemia of the disc, blurring of its borders, vasodilation, deposition of exudate along the vessels and in the vascular funnel, as well as hemorrhages in the tissue and retina. Such changes may be absent at the beginning of retrobulbar neuritis, then visual acuity suffers first of all. There may be pain when moving the eyeball. With retrobulbar neuritis, the papillomacular bundle is more often affected, which is then manifested by blanching of the temporal half of the disc. After retrobulbar neuritis, descending atrophy of the optic nerve develops.

Characteristic of damage to the optic nerve in its intracranial part (opticochiasmal arachnoiditis) are complaints of a decrease in visual acuity (which is confirmed during examination), a change in the visual field of the chiasmatic type, manifested in the loss simultaneously in both eyes of the corresponding or opposite parts of the visual field (hemianopsia) . On the fundus of the pathology is not detected.

The disease is usually bilateral, prolonged, and may be accompanied by headache. With the development of the process in the fundus, there may subsequently be phenomena of stagnation of the optic nerve head and its atrophy. Pneumoencephalography, lumbar puncture help the diagnosis.

Treatment of neuritis etiological. It is necessary to prescribe antibiotics in combination with B vitamins, urotropin, glucose infusions, tissue therapy, nicotinic acid, angiotrophin, dibazol, aloe, FIBS.

Treatment should be long, repeated courses, since part of the visual fibers may be functionally inhibited or be in a state of parabiosis, i.e., have the ability to recover. If a patient has optic-chiasmatic arachnoiditis, the intervention of a neurosurgeon is possible. The operation is indicated for persistent progressive loss of vision, as well as an increase in the central scotoma, and consists in dissecting the moorings around the optic nerve and chiasm.

3. Congestive nipple (disk) of the optic nerve (papillitis oedematosa s. oedema papillae n. optici)

Causes of a congestive disc are volumetric processes in the brain that lead to an increase in intracranial pressure: tumors, brain abscesses, gummas, tuberculomas, cysticercosis, meningiomas, hydrocephalus, injuries of the skull and orbits. Diagnosis is aided by targeted examinations.

Attention should be paid to the data of the anamnesis indicating hypertension syndrome, x-ray of the skull, diagnostic lumbar puncture, bilateral process in the fundus.

Changes in the fundus, characteristic of a congestive nipple, vary depending on the stage of the process. Initially, the patient does not complain, visual acuity is not changed. In the fundus, congestive hyperemia of the disc, blurring of its borders due to retinal edema, which spreads along the vessels and increases it in the upper and lower sections, are noted. As a result, an increase in the blind spot is determined, which is of great importance for diagnosis. Subsequently, the optic nerve disk increases in size, its marginal edema increases, the disk protrudes into the vitreous body, the veins expand, and the arteries narrow, the vessels sink in the edematous retina, hemorrhages appear from the dilated veins on the disk, and white foci of transudate are determined near the disk. Visual acuity gradually decreases, the blind spot increases even more.

In the future, a significant increase and blanching of the optic nerve is determined in the fundus, which mushroom-like protrudes above the level of the retina by 23 mm, which is determined using direct ophthalmoscopy. In the macular area, a "star" pattern may be observed. Patients complain of a significant decrease in vision. Vision changes depend on the localization of the pathological process in the brain.

Bitemporal and binasal hemianopsia are observed when the process is localized in the chiasm region, for example, with pituitary tumors, craniopharyngiomas. Homonymous hemianopsia is a consequence of the impact of the pathological focus on the visual tracts.

With a long-term congestive disc, the edema gradually decreases, the disc becomes grayish, its contours are indistinct, the caliber of the veins normalizes, and the arteries remain narrow. Subatrophy of the optic disc develops. Visual functions are still partially preserved.

If the process progresses, secondary atrophy of the optic nerve develops, which is expressed in the fact that the disc becomes white, its boundaries are fuzzy, the vessels narrow, especially the arteries, and the patient goes blind.

4. Atrophy of the optic nerve (atrophia nervi optici)

The disease occurs as a result of an inflammatory or congestive process in the optic nerve, accompanied by a progressive decrease in visual acuity and a characteristic picture of the fundus (blanching of the optic nerve head, vasoconstriction).

With primary atrophy of the optic nerve, the borders of the disc are clear, and with secondary indistinct. Secondary atrophy of the optic nerve is observed after papillitis or congestive nipple, primary after retrobulbar neuritis, optochiasmal arachnoiditis, with spinal tabes.

In addition, secondary atrophy of the optic nerve can occur as a result of many diseases of the retina of an inflammatory, dystrophic and post-traumatic nature, as well as angiocirculatory disorders. Possible congenital atrophy of the optic nerve.

Treatment. Means aimed at improving blood circulation and stimulating the remaining depressed nerve fibers (nicotinic acid injections, oxygen under the conjunctiva, vitamins B1, B12, B6, tissue therapy, intravenous glucose, glutamic acid, ultrasound treatment, cysteine ​​iontophoresis, etc.).

5. Glioma of the optic nerve (glioma nervi optici)

Glioma is a primary tumor of the optic nerve. It occurs rarely and only in preschool children. The disease is characterized by three main features:

1) slowly increasing unilateral exophthalmos;

2) decreased visual acuity;

3) a picture of a stagnant disc in the fundus.

The leading symptom is an irreducible (not decreasing with pressure on the eyeball) exophthalmos, which does not change with head tilt, tension, crying. The protrusion of the eye is, as a rule, straight forward, and only sometimes there is a slight outward deviation, which is due to the localization of the tumor of the optic nerve in the region of the muscular funnel.

The tumor may spread along the optic nerve into the skull, and then there may be no exophthalmos. In such cases, X-ray examination helps to diagnose.

Glioma should be differentiated from exophthalmos in thyrotoxicosis, orbital angioma, and cerebral hernia.

The diagnosis is helped by such studies as radiography of the orbit, skull, optic nerve canal, angiography. Radioisotope diagnostics helps to exclude a malignant process in the orbit.

Author: Shilnikov L.V.

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