EYE CLINIC

Neurooftalmologi
 Cabang oftalmologi
 Manifestasi mata pada penyakit saraf
 Sebagian penyakit neurologis didiagnosis
berdasarkan gejala dan tanda pada mata
 Evaluasi kelainan di mata membantu TS bagian
lain u/ diagnosis, terapi, follow up dan prognosis
 3

Optic Nerve Disorder

 neuropati optik : kelainan Nervus optikus (N II
saraf kranial)
 Identik dengan patologi lintasan visual
 Perjalanan impuls visual yg dihantarkan nervus
optikus sangat dipengaruhi oleh bagian bagian
otak lain yg dilewatinya
 gejala dan tanda klinis optik neuropati
bermanifestasi khas dan pasti sesuai perjalanannya
 4

Topik pembahasan
 Anatomi dan fisiologi
 Patofisiologi
 Gx umum neuropati optika /intasan visual
 History
 Gejala yg menyertai
 Pemeriksaan
 penatalaksanaan
 5

Anatomi
dan fisiologi

 6

Anatomi Nervus Optikus

 Saraf II Kranial ( intraokuler, intraorbita,
intrakanalikuler, intrakranial)
 Bermula dari sel sel ganglion retina
 Dihubungkan dengan reseptor penglihatan ( batang
dan kerucut) oleh sel bipolar
 Berkumpul menjadi Akson ( nerve fiber layer)
menuju diskus optikus membentuk pola tertentu
7
 8

Nerve Fiber Layer

 Berkas papilomacular bundle
 Berkas arcuata atas dan bawah
 Berkas nasal atas dan bawah
 Semua berkas menuju diskus optikus sebagai
nervus II
9
Anatomy of visual pathway
Nasal
Temporal retina retina Temporal retina

Optic nerve
Optic tract

Optic
chiasm
Optic radiation Lateral geniculate
body

Modified from Kahle W.Frotscher M: Color Atlas

and Textbook of Human Anatomy. 5th ed.
Striate cortex Stuttgart: Thieme. Vol.3 p.355, 2003
 11

FISIOLOGI
 Visual Pathways

Rod & Cone Cortex 17,18,19

Bipolar cells Lateral corpus

geniculatum

Ganglion cells Optic tract

Optic nerve Chiasma

 Pg. 2

The Visual Pathway

13

Pathway extends from the ‘front’ to the

VISUAL
FIELD ‘back’ of the brain.
• Precise retinotopic organization
• Deficits due to lesions of the
RETINA
pathway give valuable localizing
information.

ON
OC

OT

LGN
OPTIC
RADIATIONS

ON = Optic Nerve
OC = Optic Chiasm
OT = Optic Tract
LGN = Lateral Geniculate Nucleus of Thalamus
VISUAL
CORTEX
Beginning of the Pathway
14

Pg. 2
 Pg. 2
15
Ganglion cells axons form the optic nerve

Bipolar cells

Cells
Rods and Cones
(Receptors) of the
Retina
 Pg. 2
16
Object to be seen

The next slide looks at the

retina as if you are looking
through the patient’s pupil
via your ophthalmoscope.

Peripheral Retina

Central Retina (fovea

in the macula lutea)
 Pg. 2
17

Retinal Quadrants
Right retina Left retina

Vertical Meridian
UTQ UNQ UNQ UTQ
nose
LTQ LNQ LNQ LTQ Horizontal Meridian

Macula with Papilla (optic

fovea centralis nerve head)

Retina as you would see it through the

ophthalmoscope & the patient’s pupil
Temporal Hemiretina Nasal Hemiretina
UTQ = upper temporal quadrant UNQ = upper nasal quadrant
LTQ = lower temporal quadrant LNQ = lower nasal quadrant

The blind spot in the Visual Field corresponds to the location of

the optic nerve head on the NASAL side of the retina.
 18

DIAGNOSIS
 Gejala Umum :

1. Penurunan tajam penglihatan ( visus )

2. Kelainan lapang pandangan ( sentral perifer )
3. Kelainan penglihatan warna
4. Berkurangnya kecerahan

Gejala yang menyertai

( TIK, endokrin, n.cranialis lain )
 
HISTORY
.

Age
Duration of visual loss or changes
Bilateral or unilateral
Trauma
Photophobia
Headache
Pain
Prior episodes/ophthalmologic history
Comorbid conditions
The appearance of the eye itself
 Unilateral vs Bilateral?
Time course of Visual Loss ?
Associated Symptoms ?
 Time Course of Visual Loss

Sudden onset

- ischemic retinal ( within minutes )

- ischemic optic nerve ( within hours )

- ischemic → inflammation ( within

days – weeks )
Gradual progression

-toxic lession
- compression
 Associated Symptoms

 Pain
 Diplopia
 Ataxia
 Hemiparesis
 Hemisensory changes
Penyebab Neuropati Optik

1. Kln. Vaskuler
2. Tumor
3. Radang
4. Trauma
5. Kongenital
6. Degenerasi
 26

Defek lapang pandangan

4 teritorial
Teritorial 1 : fotoreseptor dan koroid, sifat monokuler,
tidak terlokalisir distribusi saraf, tidak ditentukan
garis vertikal
Teritorial 2 : lapisan sel ganglion, serabut saraf dan
nervus optikus, sifat monokuler, sesuai distribusi
saraf, cenderung terbatas di atas atau dibawah garis
horisontal
Teritorial 3 : chiasma, sifat heteronim
Teritorial 4 : pasca chiasma, homonim
 27

Sensitifitas dan kerentanan

 Discus optikus : kompresi gangguan vaskuler
glaukoma
 N II retrobulber tu serabut macula : bhn toksik,
metabolik, herediter, kompresif, MS
 N II intrakanlikuler : kompresi, penyakit tulang
 Chiasma : tumor, anaurysma
 Pasca chiasma : vaskuler dan tumor
 Pg. 6

Lesions of the Visual Pathway

Left Right
28

1. Normal visual fields

2. Blindness of the right eye

3. Blindness of right eye + contralateral left upper

quadrantanopia

4. Bitemporal heteronymous hemianopsia

5. Left homonymous hemianopsia

6. Left upper homonymous quadrantanopsia

7. Left homonymous hemianopsia with macular

sparing
EXAMINATION
EXAMINATIONS
Pemeriksaan visus
Pemeriksaan segmen anterior
Pemeriksaan oftalmoskopis
Pemeriksaan gerak bola mata dan fungsi
levator
Pemeriksaan lapang pandang
Uji konfrontasi
Kisi amsler
Melihat muka
Perimetri
Pemeriksaan persepsi warna, kecerahan
Pemeriksaan reflek pupil (RAPD)
Pemeriksaan kelainan yang menyertai
Pemeriksaan penunjang

 USG, Foto fundus, OCT, FFA

 Foto kepala, CT scan, MRI
PEMERIKSAAN DEFEK REFLEK
PUPIL AFEREN
( MARCUS GUNN PUPIL )
FUNDUSCOPY
Visual Fields
- Confrontation test
- Amsler grid
- Perimetri
Confrontation testing
Amsler grid
Ishihara Test
• Spatial Contrast
Spatial Sensitivity
contrast – Pelli Robson Test
sensitivity
 41

Penatalaksanaan
 Tergantung causa , cari penyebab
 Kortikosteroid
 Neurotropik vitamin
 Neuroprotektor
 Antiglaukoma
 Konseling
 Imunomodulator
 Konsul TS lain : Saraf, Bedah saraf, IPD dll
Maculopathy vs Optic Neuropathy
 Positive scotoma
 Metamorfopsia >>
 Amsler grid : wavy lines
(distorted)
 PSRT : prolonged
 Normal pupillary reaction
 Color desaturation isnt
present in mild macular
diseases
 Negative scotoma
 No metamorfopsia
 Amsler grid : missing/faint
lines
 PSRT : not prolong
 Relative afferent pupillary
defect
 Color desaturation is present
in early optic nerve disease
5 Keys steps for assessment of
optic nerve function
 VA

 Colour Vision

 Relativeafferent
pupillary defect

 Visual Field

 Optic Nerve
 44

SEKIAN
Papillo-macular bundle
3. Relative
Afferent
Pupillary Defect
3. Relative Afferent Pupillary
Defect
 Objective sign of optic nerve compromise

 Can be used to monitor progression

 Provides a comparison of the two optic nerves

Relative Afferent Pupillary Defect (RAPD)
 Testin dim room with pt looking at the distance
 Use bright source of light about 30cm from pt’s eyes
 Swing light b/w the eyes (2-3 sec on each eye)
 Make your decision within 2-3 swings
 Anatomy of
Right eye
visual pathway
Left eye

Temporal Nasal Nasal Temporal

Anatomy of visual pathway
Nasal
Temporal retina retina Temporal retina

Optic nerve
Optic tract

Optic
chiasm
Optic radiation Lateral geniculate
body

Modified from Kahle W.Frotscher M: Color Atlas

and Textbook of Human Anatomy. 5th ed.
Striate cortex Stuttgart: Thieme. Vol.3 p.355, 2003