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Optic nerve

& visual
pathway
Dr. Tara M. Hassan

OPTIC NERVE
Anatomy
Afferent fibres. The optic nerve carries
approximately 1.2 million afferent nerve
fibres, each of which originates in a retinal
ganglion cell. Most of these synapse in the
lateral geniculate body, although some
reach other centres, notably the pretectal
nuclei in the midbrain. Within the optic
nerve itself the nerve fibres are divided into
about 600 bundles by fibrous septae derived
from the pia mater.
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Surrounding layers
The innermost layer is the
delicate and vascular pia mater.
The outer sheath comprises the
arachnoid mater and the tougher
dura mater which is continuous
with the sclera; optic nerve
fenestration involves incision of
this outer sheath. The
subarachnoid space is continuous
with the cerebral subarachnoid
space and contains CSF.
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Anatomical subdivisions
The optic nerve is approximately 50 mm
long from globe to chiasm. It can be
subdivided into four segments:
Intraocular segment (optic nerve head)
is the shortest, being 1 mm deep and
approximately 1.5 mm in vertical diameter.
The ophthalmoscopically visible portion is
called the optic disc.
Intraorbital segment is 2530 mm long
and extends from the globe to the optic
foramen at the orbital apex. Its diameter is
34 mm because of the addition of the
myelin sheaths to the nerve fibres.
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Intracanalicular segment traverses


the optic canal and measures about 6
mm. Unlike the intraorbital portion, it is
fixed to the canal, since the dura mater
fuses with the periosteum.
Intracranial segment joins the
chiasm and varies in length from 5 to
16 mm (average 10 mm). Long
intracranial segments are particularly
vulnerable to damage by adjacent
lesions such as pituitary adenomas and
aneurysms.
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Signs of optic nerve dysfunction


Reduced visual acuity for
distance and near is common.
Relative afferent pupillary
defect
Dyschromatopsia is
impairment of colour vision,
which in the context of optic
nerve disease mainly affects red
and green.
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Diminished light brightness


sensitivity, often persisting after
visual acuity returns to normal, for
instance following the acute stage of
optic neuritis.
Diminished contrast sensitivity.
Visual field defects, which vary
with the underlying pathology, include
diffuse depression of the central visual
field, central scotomas, centrocaecal
scotomas, nerve fibre bundle and
altitudinal
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Classification of optic neuropathy by


cause
Inflammatory. Optic neuritis, including demyelinating,
parainfectious, infectious and non-infectious, and
neuroretinitis.
Glaucomatous.
Ischaemic. Anterior non-arteritic, anterior arteritic,
posterior ischaemic and diabetic papillopathy.
Hereditary. Leber hereditary optic neuropathy, other
hereditary optic neuropathies.
Nutritional and toxic.(tobacco and alcohol)
Papilloedematous. Secondary to raised intracranial
pressure.
Traumatic.
Compressive. Including secondary to an orbital lesion.
Infiltrative. Inflammatory conditions (e.g. sarcoidosis),
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tumours and infective agents.

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PUPILLARY LIGHT RESPONSE


The pupillary light response is an

objective indicator of anterior visual


pathway function, in general, but it is a
particularly practical and sensitive
measure of optic nerve dysfunction. The
speed and amplitude of the pupillary light
reaction generally depend on the overall
intensity and speed with which the
afferent neural signal is transmitted to the
brain stem. Diseases of the retina, optic
nerve, chiasm, and tract produce definite
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Visual Loss Arising From Structures

Anterior to the Optic Nerve.


Retinal microembolization or
hypoperfusion
Retinal migraine
Acute glaucoma (corneal edema)
Reversible cataract (e.g., acute
hyperglycemia)
retinal inhibition)
Quinine, digitalis, clomiphene citrate
Visual Loss Arising From Optic Nerve
and Chiasm
Obscurations preceding ischemic optic
neuropathy
Optic disc swelling
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Visual Loss Arising From

Postgeniculate Structures

Carotid or vertebrobasilar ischemia


Occipital lobe cerebrovascular

accidents
Classic migraine
Occipital trauma

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clinical problems:

A. Myelinated nerve fibers. Retina is


white, opaque, with feathered edges
B. Calcified astrocytic hamartoma of
retinal nerve fiber layer in tuberous
sclerosis.
C. Hypoplasia of the optic nerve. Disk
is small and with pigment rim and
surrounding paler ring.
D. Inferior crescent. Disk is small and
horizontally oval with scleral crescent
at lower border.
E. Pseudopapilledema; congenital
elevated disk compare with true
papilledema.
F. Chronic moderate papilledema

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Some of the Optic nerve clinical


problems.

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Causes of Optic Neuritis


1.Unknownorigin
2.Multiplesclerosis
3.Viralinfectionsofchildhood(measles,mumps,
chickenpox)withorwithoutencephalitis
4.Postviral,paraviralinfections
5.Infectiousmononucleosis
6.Herpeszoster
7.Contiguousinflammationofmeninges,orbit,sinuses
8.Granulomatousinflammations(syphilis,tuberculosis,
cryptococcosis,sarcoidosis)
9.Intraocularinflammations

papilloedema
Papilloedemaisdefinedasswellingoftheopticnerve
headsecondarytoraisedintracranialpressure.Itis
nearlyalwaysbilateralalthoughitmaybe
asymmetrical.Allothercausesofdiscoedemanot
associatedwithraisedintracranialpressure(e.g.optic
papillitis,centralretinalveinocclusion)arereferredto
as'discswelling'andusuallyproducevisual
impairment.Allpatientswithpapilloedemashouldbe
suspectedofhavinganintracranialmassuntilthereis
prooftothecontrary.notallpatientswithpapilloedema
willhaveatumour,assomemayhavebenign
intracranialhypertensionorotherpathology.

The following are its main features:


1. Visual symptoms are absent and visual acuity
normal.
2. Optic discs showing hyperaemia and
indistinctness of the disc margins,
3. Loss of previous spontaneous venous pulsation. If
venous pulsation is well preserved the diagnosis
of papilloedema is unlikely
4. Optic discs showing venous engorgement,
elevation of the surface, partial obscuration of the
small traversing blood vessels and obliteration of
the cup
5. flame shaped haemorrhages and cotton-wool
spots.

Papilledema.
A. Papilledema of raised intracranial

pressure. In patient with frontal


astrocytoma, right disk shows early
edema of superior pole.
B. Left disk of same patient shows
more advanced edema, yet absence
of hemorrhages, exudates, or
engorgement.
C. Fully developed Papilledema in a
case of pseudo tumor cerebri.
Multiple superficial infarcts of nerve
fiber layer (cotton-wool spots).
Veins are dilated and tortuous.
D. Severe Papilledema associated
with dural venous sinus thrombosis in
young boy. Note exudative partial
star figure at fovea.
E. Chronic Papilledema of many
months duration.
F. Chronic Papilledema after
detumescence of edema, revealing
pallor and formation of
retinochoroidal venous shunts. 24