|Year : 1958 | Volume
| Issue : 3 | Page : 49-51
Vascular atrophy of the optic nerve
SP Gupta, Ram Singh
King George's Medical College, Luchnow, India
|Date of Web Publication||8-May-2008|
S P Gupta
King George's Medical College, Luchnow
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta S P, Singh R. Vascular atrophy of the optic nerve. Indian J Ophthalmol 1958;6:49-51
| Case Report|| |
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|| |
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|| |
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|| |
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.
The differential diagnosis is discussed.
| References|| |
Barthels (1912) quoted in 4.
Callon, P. (1891) Trans. Amer. Ophth. Soc., 6, 174.
Davidson (1938), Amer. J. Ophthal., 21, 7.
Duke-Elder, W. S. Text Book of Ophthalmology, Vol. IV.
Elwyn, H. (1940) quoted in 4.
Hughes, E. B. C. (1945), Brit. J. Oph-thal. 29, 629.
Hughes, E. B. C. (1946), Trans. Ophthal. Soc. U. K., 65, 35.
Lowenstein, A. (1945) quoted in 4. 9.
Pichler, (Nil) quoted in 4.
Rodger, F. F. (1943), Brit. J. Ophthal. 27, 23.
Traquair, H. M. (1949). An Introduction to Clinical Perimetry, 6th Edit.,p. 202, 203, 204.
Turner, J. W. A. (1943), Brain, 66, 140.
[Figure - 1]