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VISUAL LOSS
By : Poppy Andita
 Anamnesis dan Topical Diagnosis
1.Distribution : -Persistent
- Monocular 4.Development
(prekiasma) -Akut/kronik
- Binocular -Menetap/progresif/remisi
(kiasma, retrokiasma, prekiasma bilateral) -Pencetus
-Binocular : bersamaan/sekuensial
2.Description :
-Kualitatif 5.Detection/gejala penyerta
(visus,lapang pandang,buram,bercak2,distorsi) -Painfull/painless
-Kuantitatif -Defisit neurologis lain
(seluruh bagian/bagian ttn ; sisi temporal, altitudinal, tunnel
-Gejala sistemik , gang endokrin
vision dll)

6.Disease
3.Duration :
RPD / FR
-Transient
 Anamnesis dan Topical Diagnosis

Durasi Gangguan penglihatan transient

Monokular
Detik Amaurosis pada massa orbita
Menit Amaurosis fugax (TIA sirkulasi anterior)
Impending neurooptik permanen (AION, dll)
Epileptic visual loss
Menit - jam Migrain retina
Binokular
Hipotensi ortostatik
Peningkatan TIK (transient obscuration)
TIA sirkulasi posterior
Migrain dengan aura tipikal
 Acute: coming on
instantaneously, or Subacute: coming on Chronic: coming on
over seconds to over days to weeks. over months to years
minutes.

• compressive,
• infiltrative, or
• degenerative
process
• Ischemic / inflammatory injury to the optic nerve.
• Vitreous hemorrhage
• Retinal detachment
VISUAL FIELD TESTING
• Goldman kinetic perimetry
• Aksis z  sensitivitas
• Sensitivitas fovea >>, > cepat
turun pada nasal
• Tiap level sensitivitas beda
• Low sensitivity  lap pandang >
lebar
• Blind spot 15o temporal sedikit
inferior
• Sudut temporal dapat diperiksa
hingga 90o, nasal 60o

• normal :
temporal 100-110o, nasal 60o
VISUAL FIELD TESTING • Amsler gird
• Computerized threshold perimetry • Sudut penglihatan 10o
• Sudut penglihatan 30o • 35 cm

• Tangent Bjerrum
• Sudut penglihatan
• 20-30o
• 1 meter
Penglihatan warna Funduskopi Tajam Penglihatan/visus

• Bedsite
• Snellen cart
• Rosenbaum
chart
 Media
okular
Okular
Retina Monokular
Prekiasma

N. Optikus
Jaras
Kiasma
Visual
Binokular

Retrokiasma
Okular
Cahaya
 kornea, anterior chamber,
lensa (pupil), vitreous  retina

Gangguan
refraksi

Katarak
Sel batang :
malam hari magnoceluler

Sel Sel Bundle of axons

bipolar ganglion n. opticus
Kerucut :
cahaya/warna parvoceluler

Blind
Parvoceluler > spot

Avascular
zone

Temporal Nasal
 Makulopati VS Optik neuropati
-Metamorfosia  amsler grid -Darkening of vision
-Photopsia -Transient visual obsuration
-Hemeralopsia -Pain
-Night vision loss
-Fotostress recovery abN -Fotostress recovery normal

-Mild dischromatopsia -Dischromatopsia

-Reduce acuity -Reduce acuity

-RAPD rare (only severe) -RAPD (+)

-Visual field : monocular -Visual field : monocular

central, midperifer central, arcuate, nasal, altitudinal,
periferal
-Fundus : pallor, macular abN
(pigment, atrophy,edema) -Fundus : edem, pallor/normal

-VEP small delay latensi -VEP large delay latensi

Makulopati Ocular coherence tomography Optik neuropati
Normal /Layers
Layers fluid menipis
retinal edema
macula hole
thinkening abN
Makulopati VS Optik neuropati

Diabetic ischemic maculopathy

Central visual loss
Edema macular
Retinopati proliferative/non proliferative
Fundus : retinal hemoragik, multiple cotton
wool spot, narrowed vessel, atrophy optic
 Arteri retina sentral :
2/3, superfisial head

Arteri siliari posterior :

1/3, bag. Luar, belok
pada antara lamina
koroidalis & kribosa 
segmental
swelling/atrofi
 Makulopati VS Optik neuropati
Retinal vascular
insufficiency
Etio : Emboli a. karotis, APS, defisiensi protein S dll

Amourosis fugax CRAO BRAO

Transient monocular Permanen Permanen

Mendadak Akut Akut
≤ 10 menit Fundus : retinal Retina bag temporal
Altitudinal, sentral opacity, macular
Photopsia (-) cherry red spot
Fundus (n)
 Makulopati VS Optik neuropati
Retinal venous occlusion
insufficiency
Berhubungan dg FR sistemik : HT, hiperkogulasi, abN jar konektif

CRVO BRVO
Acute visual loss Superotemporal
Permanent kuadran arcuata
Photopsia (+)
Fundus : edem disc, tortous dilated
vein, hemorage, cotton wool
Non ischemic & ischemic
 Makulopati VS Optik neuropati
Nervus
optikus
• Monokular
Intraocular • Diskromatopsia
• Transient visual obscuration
• Visus ↓
• Contrast sensitivity ↓
Intrakanalikular
Subarachnoid space
• Pulfrich phenomenon
Vulnerable tight space • RAPD (+) ipsi lesi
: trauma/sol • Funduscopy :
• Disc swelling/disc atrophy often
2nd
Intrakranial • VEP large delay latensi
End :
kiasma optikum
RAPD (+) ipsilateral lesi
Optik Neuropati
 Optic Neuritis
Inflamatory 2nd demyelination
Idem optic neuropathy :
Painful – optic nerve swelling
(+) Uhthoff’s symptom
 AION

Nerve fiber bundle visual field :

altitudinal, arcuate, segmented visual
loss / central
 Visual Field Defect
Optik neuropati

Generalized constriction
Centrocecal defect, Fiber bundle defect, arcuata
central defect attached
blind spot

Fiber bundle defect,central scotoma

Altitudinal, nasal step
 Visual deficit associated
papilledema
-Disfungsi optic nerves head
-Reversible with decompression

-enlarge blindspot
-Infranasal constriction vulnerable
-peripheral/difuse constriction

-transient visual obscuration : puff of smoke

 - Visual loss gradually progresif
DISORDERS of - Etio : massa kompresif sella
>
- PD : ACA, art komunikan
CHIASMAL - Acute visual loss <
anterior
- RAPD (+)

Prefixed : Fixed :
homonim hemianopsia bitemporal Post fixed :
kontralateral (15%) (80%) Monokular (5%)
 Tengah kiasma
Bitemporal hemianopsia

Temporal ipsi : nasal kontralateral

Incomplete asymmetric bitemporal denser superior

Incomplete asymmetric bitemporal denser inferior

Anterior kiasma Posterior kiasma

Central bitemporal
Juctional syndrome hemianopic scotomas
 Funduskopi :
DISORDERS of long processes  optic atrofi
CHIASMAL ventricular compression  papilledema
Sinus kavernosus : ocular motor palsy, facial pain
(n.V)
Disfungsi endokrin
DISORDERS of Complete bitemporal hemianopsia
CHIASMAL

Hemifield slide
Trouble near task phenomena
object behind
invisible
 Optic tract

lateral
RETROKIASMAL geniculate nucleus
DISORDERS
optic radiations

striate cortex

Hemianopsia homonimus dengan visus normal

Etiology and localization in adults versus children
TRAKTUS OPTIKUS
 Hemianopsia homonim
inkongruen
 Visus baik
 RAPD ipsilateral
terganggu
Kanan Kiri

Kiri Kanan

ETIO >
Tumor/Ca, aneurisma
Kiri Kanan
 TRAKTUS
OPTIKUS
 Atrofi optikus bilateral
Presynaptic ganglion cells
interupted (kiasma/n.optikus)

 Gejala lain

Kanan Kiri

Ipsilateral temporal pallor

Kontralateral bow tie & band atrofi
NUKLEUS GENIKULATUM LATERAL
ETIO superior
Oklusi a. koroid

Makula
Unkus, fusiform
inferior
girus, temporal Hilum
Hilum Hilum

6
Kornu medial Kornu lateral
5

4 3
2
1
Nasal Temporal
Med, lat
Kapsula interna,
thalamus,
pedunculus
serebral Magnoseluler 1,2

Parvoseluler 3-6
NUKLEUS GENIKULATUM
LATERAL
 Horizontal homonym
sektoranopia (pos)
 Upper & lower
homonmus / mirror image
 Visus
(ante)normal
 Bilateral
Visus normal
atrofi optic
 Gejala
Bilateral
lain
atrofi
: optic
 k.Posterior
Gejala lain : hemihipestesi,
 gg
k.Posterior
memori : Upper & lower homonmus sektorapia Horizontal homonym sektoranopia
 k.anterior
hemihipestesi,
: hemihipestesi,
gg memori
 hemiparesis
k.anterior : hemihipestesi,
hemiparesis
Radiasio optikus
Info visual kuadran superior kontralat meyer loop (temporal) kortex kalkarina inferior

Info visual inferior kontralat  parietal  kortex kalkarina superior

Radiasio optikus
 Kuadranopsia homonim bagian atas (pie in the sky)   Lesi bilateral RO  cerebral blindness
Meyers loop  a. koroidal anterior, cab mca lain (a.  Visus normal kecuali jk lesi bilateral
lentikulostriata dll)  RAPD normal
 Hemianopsia homonym inkomplit dense inferior  Parietal  Gg. Respon optokinetic
 cab mca : a. temporal posterior, angular dll  Gejala lain

ETIO >
Stroke
Lobus okspital
Perifer : paling anterior
Makular : > posterior 55-60%
Fovea : oksipital tip
-Cab PCA : a. kalkarina
-Pada oksipital pole :
Anastomosis a. superior
temporal oksipital silvii
cab dari MCA
Proyeksi lapang pandang
Lobus okspital

Hemianopsia homonym with Right homonymus

macular sparing lower quadranopsia

Keyhole shaped spared

central vision

Homonymous hemianopic central

scotomas Altitudinal hemianopsia
Lobus okspital

- Visus intak
- Cerebral blindness
• Kortex oksipital
bilateral
• Near respons (-)
• Refleks pupil normal
• RAPD normal
• Fundus normal
- Gejala lain :
- Upper bank
- Lower bank

ETIO >
Stroke
 Higher cortical visual function

Rekognisi objek,
memori,
motion, spastial, persepsi warna
atensi visual high resolution
(neglect) fine stereopsis
Higher cortical visual function Upper bank

Lower bank
Terima
Kasih
Makulopati VS Optik neuropati
Funduscopy appearance :
Anomalous, swollen, normal / pallor

Secondary atrophy Primary atrophy