Impairment Of Vision

CLINICAL APPROACH AND DIFFERENTIAL DIAGNOSIS (contd)

Central scotoma Characteristic of most optic nerve lesions.

RETROBULBAR NEURITIS - associated papillitis may be evident on fundoscopy; may be first sign of multiple sclerosis. OPTIC NERVE COMPRESSION

X-ray optic foramen - Orbital lesion (usually with

CT/MRI scan (orbital/intracranial).

Pupil response may be impaired (Marcus-Gunn pupil, see page 142)

Intracranial lesions

- tumour, e.g. meningioma (chordoma, dermoid)

- granuloma, e.g. tuberculoma, sarcoid (rare)

- aneurysm, e.g. ophthalmic -* angiography confirms

- tumour proptosis)

- granuloma

Lesion within optic canal

- tumour, e.g. meningioma

- granuloma

- hyperostosis, e.g. Paget's disease, fibrous dysplasia

Centro-caecal scotoma ee

The scotoma extends to involve the blind spot. Characteristic of toxic amblyopia - alcohol, tobacco.

Mononuclear blindness

OPTIC NERVE GLIOMA -LEBER'S OPTIC ATROPHY -

Arcuate scotoma

CT/MRI -* exploration large bilateral scotoma

The scotoma extends from the blind spot following the course of nerve fibres.

Characteristic of glaucoma; seen also in small lesions close to the optic disc such as choroiditis.

Direct pupillary response absent; consensual present.

Direct pupillary response absent; consensual present.

Junctional scotoma

Junctional scotoma

— indicates the presence of an optic nerve lesion immediately anterior to the chiasma.

Nasal fibres not only decussate in the chiasma, but also loop forward into the opposite optic nerve. This lesion emphasises the importance of examining the 'normal' eye in monocular impairment of vision.

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