Optic Nerve Disorders - part 3 docx

2. Ischemic Optic Neuropathies 51 had a fi nal visual outcome of hand motion or worse. All patients developed optic disc atrophy. Approximately 66% of patients had vascular risk factors, such as hypertension, diabetes mellitus, hypercholesterolemia, coronary artery disease, congestive heart failure, cardiac arrhythmia, obesity, and tobacco use. The remainder had no vascular risk factors. The average duration of operation was 8.7 h. The mean decrease of hematocrit was 14.4% between the preoperative and the perioperative period. The mean decrease of systolic blood pressure was 53 mmHg between the preoperative and the perioperative period. The mean intraoperative estimated blood loss was 3.7 L. If no intraoperative hypotension is docu- mented during the surgery, then anemia is most likely, as evidenced by a mean hemoglobin level that has decreased by 40% to 50% in the perioperative period. 228 Neuroimaging of the optic nerves in the perioperative setting can sometimes show the loca- tion of the lesion in PION. In a report of a 61-year-old man with bilateral PION after cardiac bypass surgery, MRI of the orbits with diffusion-weighted and fl uid-attenuated inver- sion recovery (FLAIR) sequences can reveal abnormal hyperintensity in both intraorbital optic nerves. 245 Bilateral intraorbital optic nerve enhancement was seen on MRI 8 weeks after coronary bypass grafting in a 57-year-old woman who had hypotensive posterior ischemic optic neuropathy. 246 Histopathology demonstrates that infarction occurs in the intraorbital portion of the optic nerve in patients with perioperative PION. The central axial portion of the optic nerve is usually infarcted, and may be hemorrhagic, with sparing of the nerve periphery. Occasionally, the infarction may extend to the periphery circumferen- tially, especially in the midorbital section of the optic nerve. The loss of peripheral axons appears to correspond to constricted visual fi elds. 247–249 In the report by Nawa et al. 248 on a 67-year-old man with bilateral PION after radical neck dissection complicated by intraoperative hypotension and anemia, histopathology of the optic nerve revealed acellularity of the fi bro- vascular pial septae, swollen macrophages, some hemorrhage, and loss of myelin. The para- central pial vessels had a few small thrombi, but no emboli. Perioperative hemodynamic changes causing decreased oxygen delivery to the optic nerve are thought to cause PION. These hemodynamic factors include hypotension, anemia, increased venous pressure, a prone position during surgery, direct ocular compression, increased cerebrospinal fl uid pressure, and embolism. Another factor that may decrease oxygen delivery to the optic nerve is defective vascular autoregulation caused by vascular endothelial dysfunction. 250 It has been shown that normal compensatory vasoconstriction and vasodilation during fl uctuating blood pressures does not occur in diabetic patients. 251 This lack of vascular autoregulation during perioperative hypotensive episodes would increase the risk of developing perioperative PION. Anatomic variation of the intraorbital blood supply may also account for a patient’s susceptibility to perioperative PION. The arterial supply of the intraorbital optic nerve derives from two sepa- rate systems, the peripheral centripetal vessels and the axial centrifugal vessels. 252 The pial plexus is formed by collaterals directly from the ophthalmic artery and from collateral from other intraorbital subdivisions of the ophthalmic artery. The axial system is formed from branches of the central retinal artery after it penetrates the optic nerve sheath. These branches radiate from the central optic nerve to penetrate the parenchyma. The anastomoses between the peripheral and central vascular systems may vary among patients. Those who lack these anastomoses have a watershed zone that is more susceptible to ischemia during perioperative hemodynamic changes. 252 Treatment for PION is limited at this time. Perioperative correction of hemodynamic abnormalities may be benefi cial in certain instances. In a report by Stevens et al., 242 correction of anemia and hypotension led to com- plete visual recovery in one patient, who received blood transfusions to maintain a hematocrit above 35% and a blood pressure about 140/80 mmHg by discontinuation of antihyper- tensive medications. Postoperative visual acuity was 20/70 in the right eye (OD) and 20/200 in the left eye (OS). After transfusion, visual acuity 52 J.W. Chan was 20/40 OD and 20/30 OS. Seven months later, his visual acuity improved to 20/20 OU. This report suggests that early transfusion for perioperative anemia can prevent perioperative PION. Specifi c clinical guidelines for transfusion have been controversial, and the decision to transfuse should be based upon the patient’s risk of developing complications of decreased oxygenation. 253 In addition, simultaneous internal jugular vein ligation should be avoided to prevent PION after radical neck dissection. Staging of the neck dissection does not appear to prevent PION. 254–257 PION as a Complication of Ocular or Sinus Surgery See “Traumatic Optic Neuropathy.” PION as a Complication of Radiotherapy See “Nutritional and Toxic Optic Neuropathies.” Treatment of PION The visual prognosis for PION is usually poor. No proven effective treatment is available to reverse visual loss. 19 References 1. Johnson LN, Arnold AC. Incidence of nonarteritic and arteritic anterior ischemic optic neuropathy. Population-based study in the state of Missouri and Los Angeles County, California. J Neuro-Ophthalmol 1994;14(1):38–44. 2. Hayreh SS, Joos KM, Podhajsky PA, Long CR. Systemic diseases associated with nonarteritic anterior ischemic optic neuropathy. Am J Oph- thalmol 1994;118(6):766–80. 3. Boghen DR, Glaser JS. Ischaemic optic neuropathy. The clinical profi le and history. Brain 1975;98(4):689–708. 4. 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[...]... perioperative hypotensive ischemic optic neuropathy J NeuroOphthalmol 2005;25 (3) :202–4 246 Vaphiades MS Optic nerve enhancement in hypotensive ischemic optic neuropathy J Neuro-Ophthalmol 2004;24 (3) : 235 –6 247 Johnson MW, Kincaid MC, Trobe JD Bilateral retrobulbar optic nerve infarctions after blood 61 248 249 250 251 252 2 53 254 255 256 257 loss and hypotension A clinicopathologic case study Ophthalmology... malignancies, 133 systemic lupus erythematosus,110–112 protein C and S deficiencies, 134 antithrombin III deficiency, Factor V Leiden mutations, 135 , 136 anticardiolipin antibodies, 137 , 138 oral contraceptive use, 139 and pregnancy.116 IIH appears to be associated with coagulation disorders and polycystic ovarian syndrome Exogenous estrogens or pregnancy can predispose patients with these underlying disorders. .. the angulated nerve fibers exiting the optic nerve head.40,41 Possible Mechanisms of Visual Loss Related to Papilledema Histological evidence and the types of visual field defects seen in IIH localize the site of the lesion at the optic nerve head Increased ICP is translated along the subarachnoid space of the optic nerve sheath, which causes an increased pressure gradient across the optic nerve head This... Frontal lobe or olfactory groove tumors compress the ipsilateral optic nerve to cause optic atrophy Meanwhile, growth of the mass causes increased intracranial pressure, which then distends the contralateral optic nerve sheath, resulting in papilledema Previous lesions in the optic chiasm or optic tract can also lead to asymmetric papilledema. 23 26 Patients with temporal hemianopia and atrophy of nasal... of optic disc swelling may not be so apparent Fluorescein angiography may diagnose early papilledema in only some instances .33 ,34 An A- and B-scan ultrasound with a 30 ° test when indicated can help determine whether the optic disc is truly swollen and if there is increased ICP .35 A computed tomography (CT) scan of the orbits can delineate calcium deposits to distinguish the drusen from papilledema To... patients,176 80% had flattening of the posterior sclera, 70% had an empty sella, 50% had enhancement of the prelaminar optic nerve, 45% had distension of the perioptic subarachnoid space, 45% had vertical tortuosity of the orbital optic nerve, and 30 % had intraocular protrusion of the prelaminar optic nerve These findings were absent or seen in less than 5% of the 20 control patients These radiologic signs are... JB, et al Ischemic optic neuropathy: a complication of cardiopulmonary bypass surgery Neurology 1982 ;32 (5):560–2 244 Cheng MA, Sigurdson W, Tempelhoff R, Lauryssen C Visual loss after spine surgery: a survey Neurosurgery 2000;46 (3) :625 30 245 Purvin V, Kuzma B Intraorbital optic nerve signal hyperintensity on magnetic resonance imaging sequences in perioperative hypotensive ischemic optic neuropathy... red-green abnormalities No afferent papillary defect is detected in most instances of papilledema (bilateral) One-third of patients have horizontal diplopia One-fifth of these are sixth nerve palsies; the remainder have third nerve palsies, fourth nerve palsies, or hypertropias.16 Diagnostic Testing Although papilledema is most often diagnosed by careful ophthalmoscopic examination, some cases of optic. .. Vasoconstriction to endothelin-1 is blunted in non-insulin-dependent diabetes: a doseresponse study Clin Sci (Lond) 2000;99:175–9 Hayreh SS Ischaemic optic neuropathy Indian J Ophthalmol 2000 48 (3) :171–94 Practice Guidelines for blood component therapy: a report by the American Society of Anesthesiologists Task Force on Blood Component Therapy Anesthesiology 1996;84 (3) : 732 –47 Kirkali P, Kansu T A case... relieve headaches in one-third of patients undergoing unilateral ONSD.184,187,189 Lastly, a more likely hypothesis is that postoperative scarring of the arachnoid shifts the pressure gradient posteriorly from the lamina cribrosa to the myelinated portion of the optic nerve1 90, 191 to protect the optic nerve head from elevated CSF pressure Improvement in blood flow to the optic nerve has been shown in . hypotensive ischemic optic neuropathy. J Neuro- Ophthalmol 2005;25 (3) :202–4. 246. Vaphiades MS. Optic nerve enhancement in hypotensive ischemic optic neuropathy. J Neuro-Ophthalmol 2004;24 (3) : 235 –6. 247 in end-stage arteritic and nonarteritic anterior ischemic optic neuropathy. Ophthalmology 2001;108 (3) :5 93 8. 11. Optic nerve decompression surgery for nonarteritic anterior ischemic optic. The Ischemic Optic Neuropathy Decompres- sion Trial Research Group. JAMA 1995;2 73( 8): 625 32 . 12. Ischemic Optic Neuropathy Decompression Trial: twenty-four-month update. Arch Oph- thalmol 2000;118(6):7 93 8.

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