P1: SBT
0521779407-02 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 19:18
78 Adult Optic Neuropathiesdifferential diagnosis
■Congenital anomaly of nerve mistaken for atrophy or inflammation- nerve hypoplasia, pits, crescents, colobomas (fusion defects), optic
disc drusen
➣Heredofamilial Optic Atrophies- recessive, dominant, compli-
cated, mitochondrial (Leber’s),
neurodegenerative
Swollen disc can be caused by:
■Congenital anomaly:
➣due to ocular disease (hyopotony, uveitis)
➣inflammatory (papillitis, retrobulbar neuritis)
➣infiltrative (leukemic, sarcoidosis)
➣from systemic process (anemia, Grave’s Dz)
➣optic nerve tumor (glioma, meningioma)
➣vascular (non-arteritic AION, arteritic AION, temporal arteritis)
➣orbital tumor (hemangioma, glioma)
➣papilledema – due to raised intracranial pressure
■Inflammatory Optic Neuropathies-Multiple Sclerosis, immune-
related, infections
■Ischemic Optic Neuropathies-ischemic optic neuropathy, giant cell
arteritis, diabetic papillopathy
■Glaucomatous Optic Neuropathies – chronic open angle glaucoma
■Neoplasms and related issues – disc infiltration, optic gliomas, peri-
optic meningiomas, secondary
■neoplasms to anterior visual pathways
■Nutritional Optic Neuropathies – vitamin deficiencies, tobacco-
alcohol amblyopia
■Toxic Optic Neuropathies-drugs, toxins, misc. exposures
■Traumatic Optic Neuropathies – direct, indirect, to orbit, head and
from radiation
management
What to Do First
■decide if disc is swollen – may need ophthalmologic consultation
■decide if raised intracranial pressure is a consideration, and if so deal
with emergently
■decide if temporal arteritis is consideration – if so, must address
emergently, treat with systemic steroids (to protect the non-involved
eye) as you plan temporal artery biopsy
■decide if patient is a vasculopath and treat other systemic risk factors
for vascular compromise