Grand Rounds Conference
Janelle Fassbender, MD, PhDUniversity of Louisville
Department of Ophthalmology and Visual SciencesJuly 18, 2014
SubjectiveCC: Neurologist requesting full exam
HPI: 15 year old girl with epilepsy referred to pediatric ophthalmology by her neurologist.
History
POH: Strabismus surgery 3 years prior by outside ophthalmologist
PMH: epilepsy, asthma, attention deficit disorder
Eye Meds: NoneMeds: lamotrigine, oxcarbazine,
lisdexamfetamineAllergies: NKDA
Objective
OD OSBCVA: 20/25 20/25Pupils: 5 to 3 mm OU, No
RAPDIOP: 17 17EOM: Full FullCVF: Superonasal
Superotemporal defect defect
ObjectiveSlit Lamp Exam: External/Lids Normal OUConjunctiva/Sclera Normal OUCornea Clear OUAnterior Chamber Deep, quiet OUIris Normal OULens Clear OUVitreous Normal OU
Dilated Fundus Exam
OD: OS:
*Inferior camera artifact
Visual Fields (24-2)
OD:OS:
Left superior homonymous quandrantanopia
Pre-operative MRI BrainNormal brain MRI*Patient is rotated on table, yielding asymmetry between right and left lobes.
Post-operative MRI BrainAnterior, inferior and lateral resection of temporal lobe with cystic hygroma and normal post-operative changes.
Diagnosis Left superior quandrantanopia secondary
to right temporal lobectomy for temporal lobe epilepsy.
Treatment plan
Observe
Follow-up Year 2
Stable visual field defect
The Visual Pathway
High anatomical variability in the optic radiations Up to 15 mm anteriorly
and 15 mm posteriorly (Winston, 2013).
Optic Radiations
3 Bundles (Winston, 2013): Anterior bundle
(Meyer’s Loop) – Sharp inferolateral turn to end in lower calcarine fissure
Central bundle – passes lateral and posterior to the occipital pole
Posterior bundle – direct posterior course to the upper calcarine fissure
Optic radiationsPatient post-op
Diffusion tensor tractography – representative image (Bartroli, 2010)
Temporal lobe surgery Temporal lobe
resective surgery (Georgiadis, 2013): Broad range of
surgical options: Anterior temporal lobe resection, selective amygdalohippocampectomy
Newer approaches may spare optic radiations (Winston, 2013)
Visual field defects following temporal
lobectomy Visual field defects – 50-100%
Most commonly superior quadrantanopia (Piper et al, 2014)
Other noted complications (Georgiadis, 2013): Trochlear nerve palsy – 2.6 to 19% Transient oculomotor nerve palsy – 2.1% Hemiparesis – 4.6%
Visual cortex activity outside of scotoma expected from automated perimetry.
Population receptive field analysis of primary visual field cortex complements perimetry in
patients with homonymous visual field defects.Papanikolaou A, et al. 2014. PNAS, 11(16):E1656-1665.
References Krolak-Salom P, et al. 2000. Anatomy of optic nerve radiations as
assessed by static perimetry and MRI after tailored temporal lobectomy. British Journal of Ophthalmology, 84:884-889.
Piper RJ, et al. 2014. Application of diffusion tensor imaging and tractography of the optic radiation in anterior temporal lobe resection for epilepsy: A systematic review. Clinical Neurology and Neurosurgery, 124:59-65.
Fong KCS. 2003. Eye, 17:330-333. Winston GP. 2013. Epilepsia, 54(11): 1877-1888. Papanikolaou A, et. Al. 2014. Proc Natl Acad Sci U S A, 111(16):
E1656–E1665. Georgiadis et al. 2013. Epilepsy Research and Treatment. Bartroli V. 2010.
http://wssprojects.bmt.tue.nl/sites/bmia/SysParts/Collection.aspx?XPage=b8734eb9-59be-4ffd-8ebe-4dfe8cb40854:SetFilter:FilterField1%3d%252540ID%26FilterValue1%3d292
Top Related