Neuro-Ophthalmology

Case 16

Contributor:
Marko Tien (University of British Columbia Medical Student)

Patient Presentation: A 64-year-old woman was referred to an ophthalmology clinic for gradual, painless vision loss in the right eye over the last two months. She denied any neurological symptoms and review of systems was otherwise unremarkable. She has a history of hypertension that was controlled on medication. On presentation, her visual acuity was 20/320 OD and 20/25 OS. She had normal intraocular pressures. She had a right RAPD. Fundus examination was performed and shown below: 

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Question: What is the abnormality in the fundus photographs above? 

A Humphrey visual field (24-2) was subsequently performed and showed generalized depression of her visual field in the right eye.  

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Question: OCT RNFL was performed and shown above. Which abnormality is seen?

Question: Given the patient’s history and OCT findings, what is the most likely diagnosis?

Question: Which of the following factors is the most reliable predictor for visual recovery after surgery in cases of compressive optic neuropathy? 

Question: What is the prognosis for this patient’s visual recovery post-decompressive surgery?

Question: What OCT RNFL changes are expected post-decompressive surgery?

Question: Which of the following OCT findings can aid in differentiating cases of compressive optic neuropathy from glaucoma?

References:

1.    Danesh-Meyer, H. V., Yap, J., Frampton, C., & Savino, P. J. (2014). Differentiation of compressive from glaucomatous optic neuropathy with spectral-domain optical coherence tomography. Ophthalmology, 121(8), 1516–1523. https://doi.org/10.1016/j.ophtha.2014.02.020
2.    Rodriguez-Beato FY, De Jesus O. Compressive Optic Neuropathy. [Updated 2021 Jul 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560583/
3.    Micieli JA, Newman NJ, Biousse V. The role of optical coherence tomography in the evaluation of compressive optic neuropathies. Current opinion in neurology. 2019 Feb 1;32(1):115-23.

Learning Objectives:

1.    To review the manifestations of compressive optic neuropathies on OCT
2.    To recognize the differential diagnosis and management of compressive optic neuropathies
3.    To understand the post-operative changes that occur in the OCT and visual field