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   Table of Contents      
ARTICLE
Year : 1958  |  Volume : 6  |  Issue : 3  |  Page : 49-51

Vascular atrophy of the optic nerve


King George's Medical College, Luchnow, India

Date of Web Publication8-May-2008

Correspondence Address:
S P Gupta
King George's Medical College, Luchnow
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Gupta S P, Singh R. Vascular atrophy of the optic nerve. Indian J Ophthalmol 1958;6:49-51

How to cite this URL:
Gupta S P, Singh R. Vascular atrophy of the optic nerve. Indian J Ophthalmol [serial online] 1958 [cited 2019 Aug 21];6:49-51. Available from: http://www.ijo.in/text.asp?1958/6/3/49/40723


  Case Report Top


Ram Singh aged 20 years, electrician by occupation, complained of sudden loss of vision in the left lower field of one week's duration. He gave the history that on the 9th June, 1958 while he was descending downstairs he happened to rub his right eye and noticed that he could not see the steps by his left eye, but his far sight appeared to be normal. After tak­ing rest for some time he regained his vision. Next day when he got up he noticed the same defect which has con­tinued to persist since then. He gave no history of injury at all, not even a tri­vial one. During this attack he had no fever, or pain anywhere in the body or near about the eye-ball and there was no history of any inflammatory condi­tion of the nose or sinuses. He had no previous history of attacks of headache or vomiting. Although he denied history of syphilis, his wife had a few abor­tions and of the four full term deliver­ies, only one child survived. That child showed signs of congenital syphilis in the form of frontal bosses, periosteal nodes and rhagades.


  Clinical Invetigations Top


Vision : 6/6 in each eye.

Field of vision : Contraction of the lower visual field in the left eye. [Figure - 1].

Pupils : Both pupils reacted nor­mally and equally

Fundi : On admission both optic discs and back-ground appeared to be normal, and equal in colour. The upper retinal arteries in the left eye appeared to be narrowed.

Two months after the catastrophy, the upper part of the left optic disc had become pale, and the narrowed arter­ies showed irregularities of the blood column suggesting changes due to en­darteritis.

Cardio-vascular System : Blood pres­sure 130/80. No sclerotic changes in the palpable systemic arteries could be made out. No other abnormality was detected.

Other Systems : No abnormality detected.

Blood Examination : Wasserman reaction strongly positive. Fasting blood sugar level 100 mg. per cent. Total and differential counts were within normal limits. Bleeding-time and coagulation time were within normal limits.

Skiagrams of the base of the skull and both optic foramina were normal.

Treatment : Antisyphilitic treat­ment with 14 injections of PAM 600,000 OD and then Bismuth parenterally with iodides by mouth, produced no appre­ciable improvement.


  Discussion Top


Sudden diminution of vision with a normal fundus picture followed by an optic otrophy can be met with under three conditions : nutritional disturban­ces, trauma and vascular occlusion.

Although in the case of nutritional disturbance it is difficult to attribute to it a cause for spontaneous diminution of vision, there seems to be sufficient evidence in literature that nutritional disturbances may be responsible for this kind of optic atrophy independently or contributingly.

Trauma may affect the optic nerve in three ways : (1) small nutrient pial vessels may be torn, thus depriving por­tions of the nerve of its blood supply. (2) by diffuse neural injury, (3) intra­neural hxmorrhages or thrombosis oc­curring due to contusion -Turner (1943), Hughes (1945).

According to Hughes (1946) the brunt of the injury falls on the upper portion of the nerve where it is least mobile.

Studies of the visual field distur­bance in this type of injury has affirm­ed this hypothesis, but histological con­firmation is still lacking.

The usual history in these cases is that soon after the accident the patient notices that sight in one eye is damaged or lost, commonly ipsilateral, occasion­ally contralateral and sometimes both (Callon, 1891; Pichler, 1911 and Barthels; 1912). There may be no detectable fracture of the skull and the most interesting cases are those in which the violence has been apparent­ly very slight (Traquair, 1949). Oph­thalmoscopic changes of disc pallor usually begin towards the end of the third week. These may, however, ap­pear as late as 3 months or as early as the fourth to sixth day of injury (Rodger 1943, Davidson 1938).

A similar type of delayed atrophy takes place after a vascular accident. Case reports of vascular lesions of the Optic Nerve have been presented by Elwyn (1940), Hughes (1945) and Lowenstein (1945). Traquair (1949) was of opinion that these vascular lesions which were mainly of arterio­sclerotic nature may or may not be accompanied by high blood pressure. Duke-Elder (1949) while agreeing with the above statement adds that irregular field defects may be produced by pat­chy or diffuse arteriosclerotic atrophy often progressing to blindness.

In the case reported, history of sud­den transient loss of vision in the lower field of one eye followed by re­covery and then again by permanent loss of vision in the lower field is sug­gestive of vascular spasm followed by occlusion in a blood vessel, the upper division of the central retinal artery.

The young age of the patient with a history of syphilis suggests the cause to be syphilitic endarteritis. The lesion, after two months showed definite pal­lor of the upper part of the optic disc. Other causes producing a similar lesion in the optic nerve such as trauma, in­flammation and neoplasm can be ex­cluded in this case as there is no his­tory of even Minor injury and the skiagram of the skull and optic fora­mena depict no bony injury. Any nu­tritional disturbance, even as a con­tributory cause can also be excluded.

Common vascular lesions of the optic nerve are mainly due to arteriosclerosis and syphilis, the former usually seen in elderly patients and the latter in younger patients. There were signs of an arteriosclerotic nature in the fundus. It may or may not be accompanied by a high blood pressure. Frank arterio­sclerotic optic atrophy with field defects is not infrequent.

Arteriosclerotic atrophy is due also to obliterative sclerosis of small feeding vessels from the sheath supplying the nerve.

In differential diagnosis one should keep in mind acute retrobulbar neuritis which is sudden in onset, rapidly pro­gressive in course and shows pressure tenderness at the insertion of the supe­rior rectus-muscle.

Neoplastic lesions at this region are glioma in the young and meningioma of the optic nerve in adults. There is pro­ptosis, impaired mobility, progressive visual impairment and radiographic signs of enlargement of the optic fora­men. None of these were present in this case.

The diagnosis in this case is based on history, evidence in the child of syphilis, a positive serological reaction for syphilis and field defects with fundus changes.


  Summary Top


A brief review of the literature on Vascular lesions of the optic nerve is given and a case is presented who had occlusion of the upper division of the central retinal artery in the left optic nerve secondary to syphilitic endarteri­tis with loss of the lower field of vision and fundus changes.[12]

The differential diagnosis is dis­cussed.

 
  References Top

1.
Barthels (1912) quoted in 4.  Back to cited text no. 1
    
2.
Callon, P. (1891) Trans. Amer. Ophth. Soc., 6, 174.  Back to cited text no. 2
    
3.
Davidson (1938), Amer. J. Ophthal., 21, 7.  Back to cited text no. 3
    
4.
Duke-Elder, W. S. Text Book of Oph­thalmology, Vol. IV.  Back to cited text no. 4
    
5.
Elwyn, H. (1940) quoted in 4.  Back to cited text no. 5
    
6.
Hughes, E. B. C. (1945), Brit. J. Oph-thal. 29, 629.  Back to cited text no. 6
    
7.
Hughes, E. B. C. (1946), Trans. Oph­thal. Soc. U. K., 65, 35.  Back to cited text no. 7
    
8.
Lowenstein, A. (1945) quoted in 4. 9.  Back to cited text no. 8
    
9.
Pichler, (Nil) quoted in 4.  Back to cited text no. 9
    
10.
Rodger, F. F. (1943), Brit. J. Ophthal. 27, 23.  Back to cited text no. 10
    
11.
Traquair, H. M. (1949). An Introduc­tion to Clinical Perimetry, 6th Edit.,p. 202, 203, 204.  Back to cited text no. 11
    
12.
Turner, J. W. A. (1943), Brain, 66, 140.  Back to cited text no. 12
    


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