Optic nerve subatrophy treatment. A merciless and hard-to-treat disease: how does descending optic nerve atrophy manifest? The main classification of the disease

Acquired optic atrophy develops as a result of damage to optic nerve fibers (descending atrophy) or retinal cells (ascending atrophy).

Downward atrophy is caused by processes that damage the fibers of the optic nerve at different levels (orbit, optic canal, cranial cavity). The nature of the damage is different: inflammation, trauma, glaucoma, toxic damage, impaired blood circulation in the vessels feeding the optic nerve, metabolic disorders, compression of optic fibers by volumetric formation in the orbit cavity or in the cranial cavity, degenerative process, myopia, etc.).

Each etiological factor determines the atrophy of the optic nerve with certain typical ophthalmoscopic features, such as glaucoma, impaired blood circulation in the vessels that feed the optic nerve. Nevertheless, there are characteristics common to optic atrophy of any nature: blanching of the optic nerve head and impaired visual function.

The degree of decrease in visual acuity and the nature of visual field defects are determined by the nature of the process that caused the atrophy. Visual acuity can range from 0.7 to practical blindness.

According to the ophthalmoscopic picture, primary (simple) atrophy is distinguished, which is characterized by pallor of the optic nerve head with clear boundaries. The number of small vessels on the disc is reduced (Kestenbaum's symptom). Retinal arteries are narrowed, veins can be of normal caliber or also somewhat narrowed.

Depending on the degree of damage to the optic fibers, and, consequently, on the degree of decrease in visual functions and blanching of the optic nerve head, an initial, or partial, and complete atrophy of the optic nerve is distinguished.

The time during which the blanching of the optic nerve head develops, and its severity depend not only on the nature of the disease, which led to optic nerve atrophy, but also on the remoteness of the lesion from the eyeball. So, for example, with inflammatory or traumatic damage to the optic nerve, the first ophthalmoscopic signs of optic nerve atrophy appear several days later - several weeks after the onset of the disease or the moment of injury. At the same time, when the volumetric formation acts on the optic fibers in the cranial cavity, initially only visual disturbances are clinically manifested, and changes in the fundus in the form of optic nerve atrophy develop after many weeks and even months.

Congenital optic atrophy

Congenital, genetically determined optic nerve atrophy is divided into autosomal dominant, accompanied by an asymmetric decrease in visual acuity from 0.8 to 0.1, and autosomal recessive, characterized by a decrease in visual acuity, often to practical blindness already in early childhood.

If ophthalmoscopic signs of optic nerve atrophy are detected, it is necessary to conduct a thorough clinical examination of the patient, including the determination of visual acuity and the boundaries of the visual field for white, red and green colors, and a study of intraocular pressure.

In the case of development of atrophy against the background of edema of the optic nerve head, even after the disappearance of the edema, the boundaries and pattern of the disc remain indistinct. This ophthalmoscopic picture is called secondary (postoperative) optic nerve atrophy. The retinal arteries are narrowed in caliber, while the veins are dilated and convoluted.

When clinical signs of optic nerve atrophy are detected, it is necessary first of all to establish the cause of the development of this process and the level of damage to the optic fibers. For this purpose, not only a clinical examination is carried out, but also CT and / or MRI of the brain and orbits.

In addition to etiologically determined treatment, symptomatic complex therapy is used, including vasodilator therapy, vitamins C and group B, drugs that improve tissue metabolism, various options for stimulating therapy, including electrical, magnetic and laser stimulation of the optic nerve.

Hereditary atrophies come in six forms:

1. with a recessive type of inheritance (infantile) - from birth to three years, there is a complete decrease in vision;
2. with a dominant type (youthful blindness) - from 2-3 to 6-7 years. The course is more benign. Vision decreases to 0.1 - 0.2. In the fundus, segmental blanching of the optic nerve head is noted, there may be nystagmus, neurological symptoms;
3. optic-oto-diabetic syndrome - from 2 to 20 years. Atrophy is combined with retinal pigmentary degeneration, cataracts, diabetes mellitus and diabetes insipidus, deafness, urinary tract damage;
4. Beer's syndrome - complicated atrophy. Bilateral simple atrophy already in the first year of life, reggae drops to 0.1-0.05, nystagmus, strabismus, neurological symptoms, damage to the pelvic organs, the pyramidal pathway suffers, mental retardation joins;
5. sex-related (more often observed in boys, develops in early childhood and grows slowly);
6. Lester's disease (hereditary Lester atrophy) - in 90% of cases occurs between the ages of 13 and 30 years.

Symptoms Acute onset, a sharp drop in vision for several hours, less often for several days. A defeat of the type of retrobulbar neuritis. The optic disc at first is not changed, then blurring of the borders appears, changes in small vessels - microangiopathy. After 3-4 weeks, the optic disc becomes paler on the temporal side. Vision improves in 16% of patients. Most often, low vision remains for life. Patients are always irritable, nervous, they are worried about headache, fatigue. The reason is optochiasmatic arachnoiditis.

Optic nerve atrophy in certain diseases

1. Optic atrophy is one of the main signs of glaucoma. Glaucomatous atrophy is manifested by a pale disc and the formation of a depression - excavation, which first occupies the central and temporal regions, and then covers the entire disc. In contrast to the above diseases leading to disc atrophy, in glaucomatous atrophy, the disc has a gray color, which is associated with the peculiarities of damage to its glial tissue.
2. Syphilitic atrophy.

Symptoms The optic disc is pale, gray, vessels of normal caliber and sharply narrowed. Peripheral vision narrows concentrically, cattle does not happen, color perception suffers early. There may be progressive blindness that comes on quickly over the course of a year.

It proceeds in waves: a rapid decrease in vision, then during the period of remission - improvement, during the period of exacerbation - repeated deterioration. Miosis, divergent strabismus, changes in pupils, lack of response to light develop, while maintaining convergence and accommodation. The prognosis is poor, blindness occurs within the first three years.

1. Features of atrophy of the optic nerve from compressed la (tumor, abscess, cyst, aneurysm, sclerosed vessels), which can be in the orbit, anterior and posterior cranial fossa. Peripheral vision suffers depending on the localization of the process.
2. Foster-Kennedy syndrome - atherosclerotic atrophy. Compression can cause sclerosis of the carotid artery and hardening of the ophthalmic artery; from softening with sclerosis of the arteries, ischemic necrosis occurs. Objectively - excavation caused by the retraction of the lattice plate; benign diffuse atrophy (with sclerosis of small vessels of the pia mater) grows slowly, accompanied by atherosclerotic changes in the retinal vessels.

Atrophy of the optic nerve in hypertension is the outcome of neuroretinopathy and diseases of the optic nerve, chiasm and optic tract.

A severe, often progressive disease in which there is a gradual irreversible deterioration in visual acuity, up to the development of blindness. According to the WHO, the frequency of detection of this disease is growing all over the world, this trend is especially noticeable among the population of economically developed countries. Despite the advances in modern medicine, the search for more effective treatments for optic nerve atrophy is still ongoing.

The optic nerve is formed by the processes of the nerve cells of the retina of the eye. Retinal cells have the ability to perceive light and convert it into nerve impulses, which are then transmitted along the optic nerve to specific areas of the cerebral cortex responsible for the formation of visual images.

Due to the influence of many different factors, the fibers of the optic nerve can gradually collapse and die off, while the conduction of nerve impulses from the retina to the brain also gradually deteriorates. For a sufficiently long period of time, the process of destruction of the optic nerve fibers remains invisible to the patient, so he does not go to the doctor. At the same time, the later treatment of optic nerve atrophy is started, the worse the prognosis of the course of the disease, because it will be impossible to restore the lost vision.

Depending on the severity of the pathological process, there are isolated partial atrophy of the optic nerve (PASN) when visual functions are preserved and complete atrophy when vision is missing.

The reasons for the development of optic nerve atrophy

Atrophy of the optic nerve can be caused by a variety of reasons, including neuritis, neoplasms, glaucoma, vascular atherosclerosis, poisoning with certain substances (methanol, nicotine), acute viral infections, hypertension, retinal pigmentary degeneration, etc.

For reasons, it is customary to distinguish between several types of disease:

Primary optic atrophy

The reason for the development of primary atrophy of the optic nerve are diseases that are accompanied by impaired microcirculation and trophism of the optic nerve. It can be observed in atherosclerosis, degenerative diseases of the cervical spine, hypertension.

Secondary optic nerve atrophy

Pathology occurs as a result of edema of the optic nerve head in diseases of the retina or the nerve itself (inflammation, swelling, poisoning with surrogate alcohol, quinine, trauma, etc.).

Symptoms

Patients with optic nerve atrophy may complain of a decrease in visual acuity and the inability to restore it with glasses or contact lenses, many note soreness when moving the eyes, persistent headaches, and deterioration in color perception. Subjectively, patients may note that they see better in the dark than on a sunny day.

Diagnostics

When examining patients with suspected atrophy of the optic nerve, first of all, examination of the fundus, perimetry, determination of visual acuity, measurement of intraocular pressure is used.

The main diagnostic sign of optic nerve atrophy is visual field disturbance detected during the corresponding ophthalmological examination.

When examining the fundus, a pronounced pallor of the optic nerve head, a change in its shape or clarity, and sometimes a bulging of the central part of the disc are diagnosed.

Treatment of partial optic nerve atrophy

Treatment of optic nerve atrophy of any form should be comprehensive. The goal of treatment is to slow down the process of dying off of nerve fibers as much as possible and to maintain residual visual acuity. Conservative methods of treatment (including hardware techniques) and surgical treatment are used.

Drug treatment is aimed at improving microcirculation and trophism in the affected nerve, in order to prevent further progression of pathological changes and slow down the process of loss of vision.

Local therapy includes the use of injections of drugs to improve microcirculation, B vitamins, etc. (in the form of subconjunctival, parabulbar, retrobulbar, intravenous and intramuscular injections). Hardware and physiotherapy techniques (magnetotherapy, electrical stimulation, etc.), laser therapy, hirudotherapy are also used.

Since in many cases optic nerve atrophy is the outcome of common diseases (atherosclerosis, hypertension), treatment of the underlying disease is imperative. Patients with degenerative changes in the cervical spine are prescribed various techniques to improve blood circulation in the collar zone and relieve muscle-tonic syndrome (massage, mesotherapy, exercise therapy).

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Description

is not an independent disease. This is a consequence of a variety of pathological processes affecting different parts of the visual pathway. It is characterized by decreased visual function and blanching of the optic nerve head.

Etiology

Development of optic nerve atrophy cause various pathological processes in the optic nerve and retina(inflammation, degeneration, edema, circulatory disorders, toxins, compression and damage to the optic nerve), diseases of the central nervous system, general diseases of the body, hereditary causes.

Lead to optic atrophy common diseases... This happens in case of poisoning with ethyl and methyl alcohols, tobacco, quinine, chlorophos, sulfonamides, lead, carbon disulfide and other substances, with botulism. Vascular diseases can cause acute or chronic circulatory disorders in the vessels of the optic nerve with the development of ischemic foci and foci of softening in it (colliquation necrosis). Essential and symptomatic hypertension, atherosclerosis, diabetes mellitus, internal profuse bleeding, anemia, diseases of the cardiovascular system, starvation, vitamin deficiency can lead to optic nerve atrophy.

In the etiology of optic nerve atrophy, and diseases of the eyeball... These are retinal lesions of vascular origin (with hypertensive angiosclerosis, atherosclerosis, involutional changes), retinal vessels (inflammatory and allergic vasculitis, obstruction of the central artery and central retinal vein), degenerative diseases of the retina (including retinal pigmentary degeneration), complications, uveitis (papillitis chorioretinitis), retinal detachment, primary and secondary glaucoma (inflammatory and post-inflammatory, phlicogenic, vascular, dystrophic, traumatic, postoperative, neoplastic). Prolonged hypotension of the eyeball after operations, inflammatory degenerative diseases of the ciliary body, penetrating wounds of the eyeball with the formation of a fistula lead to edema of the optic nerve head (congestive nipple), after which atrophy of the optic nerve head develops.

In addition to Leber's hereditary atrophy and hereditary infantile optic nerve atrophy, hereditary causes play a role in the onset of atrophy with drusen of the optic nerve head. Diseases and deformities of the bones of the skull (tower-shaped skull, Cruson's disease) also lead to atrophy of the optic nerves.

It should be noted that in practice, the etiology of optic nerve atrophy is not always easy to establish. According to E. Zh. Tron, in 20.4% of patients with optic nerve atrophy, its etiology was not established.

Pathogenesis

The nerve fibers of the peripheral neuron of the visual pathway can be subjected to various influences. This is inflammation, non-inflammatory edema, dystrophy, circulatory disorders, the action of toxins, damage, compression (by a tumor, adhesions, hematomas, cysts, sclerosed vessels, aneurysms), which leads to the destruction of nerve fibers and their replacement with glial and connective tissue, obliteration of the capillaries feeding them ...

In addition, with an increase in intraocular pressure, collapse of the glial-ethmoid membrane of the optic nerve head, which leads to dystrophy of nerve fibers in vulnerable areas of the disc, and then to atrophy of the disc with excavation, arising from direct compression of the disc and secondary disturbance of microcirculation.

Classification

According to the ophthalmoscopic picture, they distinguish primary (simple) and secondary optic nerve atrophy... Primary atrophy occurs on the previously unchanged disc. With simple atrophy, nerve fibers are promptly replaced by proliferating elements of glia and connective tissue that take their places. The boundaries of the disc remain distinct. Secondary atrophy of the optic nerve head occurs on the altered disc due to its edema (congestive nipple, anterior ischemic neuropathy) or inflammation. In place of the dead nerve fibers, as in primary atrophy, glial elements penetrate, but this occurs more violently and in large sizes, as a result of which coarse scars are formed. The boundaries of the optic nerve head are not distinct, washed out, its diameter can be increased. The division of atrophy into primary and secondary is arbitrary. With secondary atrophy, the boundaries of the disc are only initially indistinct, over time, the edema disappears, and the boundaries of the disc become clear. This atrophy is no different from a simple one. Sometimes glaucomatous (marginal, cavernous, cavernous) atrophy of the optic nerve head is isolated in a separate form. With it, there is practically no proliferation of glia and connective tissue, and as a result of the direct mechanical effect of increased intraocular pressure, punching (excavation) of the optic nerve head occurs as a result of the collapse of its glial-ethmoid membrane.

Optic disc atrophy, depending on the degree of color loss detected by ophthalmoscopy, is divided into initial, partial, incomplete and complete... With initial atrophy, a slight blanching appears against the background of the pink discoloration, which later becomes more intense. If not the entire diameter of the optic nerve is damaged, but only part of it, partial atrophy of the optic nerve head develops. So, when the papillomacular bundle is damaged, blanching of the temporal half of the optic nerve occurs. With the further spread of the process, partial atrophy can spread to the entire nipple. With the diffuse spread of the atrophic process, a uniform blanching of the entire disc is noted. If, at the same time, visual functions are still preserved, then they speak of incomplete atrophy. With complete atrophy of the optic nerve, disc blanching is total and the visual functions of the affected eye (amaurosis) are completely lost. In the optic nerve, not only optic, but also reflex nerve fibers pass, therefore, with complete atrophy of the optic nerve on the side of the lesion, the direct reaction of the pupil to light is lost, and in the other eye - friendly.

Topically isolate ascending and descending optic nerve atrophy... Retinal ascending atrophy (waxy, valerian) occurs in inflammatory and degenerative processes in the retina due to the primary lesion of the visual-ganglionic neurocytes of the retinal ganglion layer. The optic disc becomes grayish-yellow, the vessels of the disc narrow, and their number decreases. Ascending atrophy does not develop when only the neuroepithelial layer of the retina (rods and cones) is affected. Descending optic nerve atrophy occurs when a peripheral neuron of the optic pathway is damaged and slowly descends to the optic nerve head. Having reached the optic nerve head, the atrophic process changes it as a primary atrophy. Descending atrophy spreads more slowly ascending. The closer the process is to the eyeball, the faster atrophy of the optic nerve head appears on the fundus. Thus, damage to the optic nerve at the entrance to it of the central retinal artery (10-12 mm behind the eyeball) causes atrophy of the optic nerve head after 7-10 days. Damage to the intraorbital segment of the optic nerve before the entrance of the central retinal artery into it leads to the development of atrophy of the optic nerve head in 2-3 weeks. With retrobulbar neuritis, atrophy descends to the fundus within 1-2 months. With injuries of the chiasm, descending atrophy descends to the fundus 4-8 weeks after the injury, and with slow compression of the chiasm by pituitary tumors, atrophy of the optic nerve head develops only after 5-8 months. Thus, the rate of spread of descending atrophy is also associated with the type and intensity of the pathological process that affects the peripheral neuron of the visual pathway. Matter and blood supply conditions: the atrophic process develops faster with a deterioration in the blood supply to the nerve fibers. Atrophy of the optic discs with damage to the optic tract occurs about a year after the onset of the disease (with injuries of the optic tract, it is somewhat faster).

Atrophy of the optic nerves can be stationary and progressive, which is assessed in the process of dynamic research of the fundus and visual functions.

When one eye is affected, they talk about unilateral, with damage to both eyes - oh bilateral optic nerve atrophy... Atrophy of the optic nerves during intracranial processes is often bilateral, but the degree of its severity is different. Occurs in intracranial processes and unilateral atrophy of the optic nerve, which is especially common when the pathological focus is located in the anterior cranial fossa. Unilateral atrophy in intracranial processes can be the initial stage of bilateral. In case of impaired blood circulation in the vessels of the optic nerve, intoxications, the process is usually bilateral. Unilateral atrophy occurs with damage to the optic nerve, pathological processes in the orbit, or is caused by unilateral pathology of the eyeball.

Ophthalmoscopic picture

With atrophy of the optic nerve, there is always blanching of the optic disc a. There is often, but not always, vasoconstriction of the optic nerve head.

With primary (simple) atrophy the boundaries of the disc are clear, its color is white or grayish-white, bluish or slightly greenish. In redless light, the outlines of the disc remain crisp or sharper, while the outlines of the normal disc are veiled. In red (purple) light, the atrophic disc becomes blue in color. The ethmoid plate (lamina cribrosa), through which the optic nerve passes when it enters the eyeball, is very little translucent. The transillumination of the ethmoid plate is due to a decrease in the blood supply to the atrophied disc and less growth of glial tissue than in secondary atrophy. Disc blanching can vary in intensity and spread. With initial atrophy, against the background of the pink discoloration, a slight but distinct blanching appears, then it becomes more intense with a simultaneous weakening of the pink tint, which then completely disappears. With advanced atrophy, the disc is white. At this stage of atrophy, vasoconstriction is almost always noted, and the arteries are narrowed more sharply than the veins. The number of vessels on the disc also decreases. Normally, about 10 small vessels pass through the edge of the disc. With atrophy, their number decreases to 7-6, and sometimes to three (Kestenbaum's symptom). Sometimes, with primary atrophy, a small excavation of the optic nerve head is possible.

With secondary atrophy the boundaries of the disc are indistinct, washed out. Its color is gray or dirty gray. The vascular funnel or physiological excavation is filled with connective or glial tissue, the ethmoid plate of the sclera is not visible. These changes are usually more pronounced in atrophy after congestive nipple than in atrophy after optic neuritis or anterior ischemic neuropathy.

Retinal waxy optic disc atrophy it is distinguished by its yellow waxy color.

With glaucoma increased intraocular pressure causes the appearance of glaucomatous excavation of the optic nerve head. In this case, first the vascular bundle of the disc is displaced to the nasal side, then the excavation of the nipple gradually develops, which gradually increases. The disc becomes whitish and pale in color. Excavation in the form of a cauldron covers almost the entire disk up to its edges (cauldron, edge excavation), which distinguishes it from physiological excavation, having the shape of a funnel, which does not reach the edges of the disk and does not displace the vascular bundle nasally. Vessels at the edge of the disc are bent over the edge of the depression. In advanced stages of glaucoma, excavation engulfs the entire disc, which becomes completely white, and the vessels on it are severely narrowed.

Cavernous atrophy occurs when the vessels of the optic nerve are damaged. The atrophic optic nerve head begins to grind under the influence of normal intraocular pressure with the appearance of excavation, while an increased intraocular pressure is required to excavate a normal disk. Excavation of the disc in cavernous atrophy is facilitated by the fact that the growth of glia is small, and therefore no additional resistance is created to impede excavation.

Visual function

Visual acuity in patients with optic nerve atrophy depends on the localization and intensity of the atrophic process... If the papillomacular bundle is affected, then visual acuity is significantly reduced. If the papillomacular bundle is slightly affected, and the peripheral fibers of the optic nerve are more affected, then visual acuity does not decrease much. If there is no damage to the papillomacular bundle, and only the peripheral fibers of the optic nerve are affected, then visual acuity does not change.

Visual field changes with atrophy of the optic nerve are important in topical diagnosis. They depend to a greater extent on the localization of the pathological process and to a lesser extent on its intensity. If the papillomacular bundle is affected, then a central scotoma occurs. If the peripheral fibers of the optic nerve are affected, then the narrowing of the peripheral boundaries of the visual field (uniform along all meridians, uneven, sector-shaped) develop. If the atrophy of the optic nerve is associated with damage to the chiasm or the optic tract, then hemianopsia (homonymous and heteronymous) occurs. Hemianopsia in one eye occurs when the intracranial part of the optic nerve is damaged.

Color vision disorders more often occur and are clearly pronounced with atrophy of the optic nerve head that occurs after neuritis, and rarely with atrophy after edema. First of all, the color perception of green and red suffers.

Often with optic nerve atrophy fundus changes correspond to changes in visual functions, but this is not always the case. So with descending atrophy of the optic nerve, visual functions can be greatly changed, and the fundus of the eye remains normal for a long time until the atrophic process descends to the optic nerve head. A pronounced blanching of the optic nerve head in combination with a slight change in visual functions is also possible. This can be in multiple sclerosis, when the death of the myelin sheaths in the plaque area occurs while the axial cylinders of the nerve fibers are preserved. The pronounced blanching of the disc, while the visual functions are preserved, may also be associated with the peculiarity of the blood supply in the region of the ethmoid plate of the sclera. This area is supplied with blood from the posterior short ciliary arteries, the deterioration of blood flow through them causes an intense discoloration. The rest (orbital) part of the optic nerve is supplied with blood from the anterior and posterior arteries of the optic nerve, that is, from other vessels.

With blanching of the optic nerve head, combined with the normal state of visual functions, it is necessary to study the visual field using campimetry to identify its minor defects. In addition, it is necessary to collect an anamnesis about the initial visual acuity, since sometimes visual acuity can be higher than unity, and in these cases its decrease to unity may indicate the influence of the atrophic process.

With unilateral atrophy a careful study of the functions of the second eye is necessary, since unilateral atrophy can only be the beginning of bilateral, which is often the case with intracranial processes. Changes in the visual field of the other eye indicate a bilateral process and acquire an important topico-diagnostic value.

Diagnostics

In severe cases, the diagnosis is not difficult. If the blanching of the optic nerve head is insignificant (especially the temporal one, since the temporal half of the disc is normally somewhat paler than the nasal half), then a long-term study of visual functions in dynamics helps to establish the diagnosis. In this case, it is necessary pay special attention to the study of the field of view for white and colored objects... Facilitate diagnosis Electrophysiological, X-ray and fluorescent-angiographic studies. Typical changes in the visual field and an increase in the electrical sensitivity threshold (up to 400 μA at a rate of 40 μA) indicate atrophy of the optic nerve. The presence of marginal excavation of the optic nerve head and an increase in intraocular pressure indicate glaucomatous atrophy.

Sometimes it is difficult to establish the type of optic nerve lesion or the nature of the underlying disease only by the presence of disc atrophy in the fundus. The blurring of the disc boundaries during atrophy indicates that it was the result of edema or inflammation of the disc. It is necessary to study the history in more detail: the presence of symptoms of intracranial hypertension indicates the post-stagnant nature of atrophy. The presence of simple atrophy with clear boundaries does not exclude its inflammatory origin. So, descending atrophy on the basis of retrobulbar neuritis and inflammatory processes of the brain and its membranes, it causes disc changes in the fundus of the type of simple atrophy. The nature of atrophy(simple or secondary) is of great importance in diagnosis, since certain diseases lead to certain, "favorite" types of damage to the optic nerves. For example, compression of the optic nerve or chiasm by a tumor leads to the development of simple atrophy of the optic nerves, a tumor of the ventricles of the brain - to the development of congestive nipples and further to secondary atrophy. However, the diagnosis is complicated by the fact that some diseases, such as meningitis, arachnoiditis, neurosyphilis, can be accompanied by both simple and secondary atrophy of the optic nerve discs. In this case, the accompanying eye symptoms are important: changes in the vessels of the retina, the retina itself, the choroid, as well as a combination of optic nerve atrophy with a disorder of pupillary reactions.

When assessing the degree of discoloration and blanching of the optic nerve head it is necessary to take into account the general background of the fundus... Against the parquet background of the fundus in brunettes, even a normal or slightly atrophied disc appears paler and white. Against the light background of the fundus, the atrophic nipple may not look so pale and white. In severe anemia, the optic discs are completely white, but more often a faint pink tint remains. In hyperopes, the optic discs are normally more hyperemic, and with a high degree of hyperopia, there may be a picture of pseudo-neuritis (severe hyperemia of the nipples). In myopia, the optic discs are paler than in emmetropes. The temporal half of the optic nerve head is normally somewhat paler than the nasal half.

Optic nerve atrophy in certain diseases

Brain tumors ... Secondary atrophy of the optic nerve in brain tumors is a consequence of congestive nipples. More often it happens with tumors of the cerebellopontine angle, hemispheres and ventricles of the brain. With subtentorial tumors, secondary atrophy is less common than with supratentorial tumors. The incidence of secondary atrophy is influenced not only by localization, but also by the nature of the tumor. It is more common with benign tumors. Especially rarely, it develops with metastases of malignant tumors in the brain, since the death occurs earlier than congestive nipples turn into secondary atrophy.

Primary (simple) optic nerve atrophy occurs when compression of the peripheral neuron of the visual pathway... Most often, chiasm is affected, less often the intracranial part of the optic nerve, and even less often the optic tract. Simple atrophy of the optic nerve is characteristic of supratentorial brain tumors, especially tumors of the chiasmatic-sellar region. Rarely, primary atrophy of the optic nerves occurs in subtentorial tumors as a distant symptom: compression of the peripheral neuron of the visual pathway is carried out through the expanded ventricular system or by dislocation of the brain. Primary optic nerve atrophy rarely occurs with tumors of the ventricles of the cerebral hemispheres, cerebellum and cerebellopontine angle, and secondary atrophy in tumors of this localization is common. Rarely, simple atrophy of the optic nerves develops in malignant tumors and often in benign tumors. Primary optic atrophy is usually caused by benign tumors of the sella turcica (pituitary adenomas, craniopharyngiomas) and meningiomas of the lesser wing of the main bone and olfactory fossa. Atrophy of the optic nerves develops in Foster-Kennedy syndrome: simple atrophy in one eye and congestive nipple with a possible transition to secondary atrophy in the other eye.

Brain abscesses ... Stagnant discs often develop, but they rarely turn into secondary atrophy of the optic nerves, since the increase in intracranial pressure is not so prolonged, since intracranial hypertension either decreases after surgery, or patients do not live to see the transition of stagnant nipples to secondary atrophy. Foster Kennedy syndrome is rare.

Optochiasmal arachnoiditis ... More often, primary atrophy of the optic nerve discs occurs in the form of blanching of the entire nipple or its temporal half (partial atrophy). In isolated cases, blanching of the upper or lower half of the disc is possible.

Secondary atrophy of the optic nerve discs in optochiasmal arachnoiditis can be postneuritic (the transition of inflammation from the meninges to the optic nerve) or post-congestive (occurs after congestive nipples).

Arachnoiditis of the posterior cranial fossa ... Often lead to the development of pronounced congestive nipples, which then turn into secondary atrophy of the optic discs.

Aneurysms of the vessels of the base of the brain ... Aneurysms of the anterior part of the circle of Willis often press on the intracranial part of the optic nerve and chiasm, which leads to the development of simple atrophy of the optic nerve. Simple atrophy with compression of the optic nerve is unilateral, always located on the side of the aneurysm. With pressure on the chiasm, bilateral simple atrophy occurs, which can first occur in one eye, and then appear in the other. Unilateral simple atrophy of the optic nerve most often occurs with aneurysms of the internal carotid artery, less often with aneurysms of the anterior cerebral artery. Aneurysms of the vessels of the base of the brain are most often manifested by unilateral paralysis and paresis of the nerves of the oculomotor apparatus.

Internal carotid artery thrombosis ... The presence of an alternating optic-pyramidal syndrome is characteristic: blindness of the eye with simple atrophy of the optic nerve head on the side of thrombosis in combination with hemiplegia on the other side.

Dorsal tabes and progressive paralysis ... With tabes and progressive paralysis, optic atrophy is usually bilateral and has the character of simple atrophy. Atrophy of the optic nerves with tabes occurs more often than with progressive paralysis. The atrophic process begins with peripheral fibers and then slowly goes deep into the optic nerve, therefore, a gradual decrease in visual functions is noted. Visual acuity gradually decreases with varying degrees of severity in both eyes, up to bilateral blindness. Fields of vision gradually narrow, especially in color, in the absence of livestock. Atrophy of the optic nerve with tabes usually develops in the early period of the disease, when other neurological symptoms (ataxia, paralysis) are not expressed or absent. Tabes is characterized by a combination of simple atrophy of the optic nerves with Argil Robertson's symptom. Reflex immobility of the pupils with tabes is often combined with miosis, anisocoria and deformation of the pupils. Argil Robertson's symptom also occurs with syphilis of the brain, but much less often. Secondary atrophy of the optic discs (post-stagnant and post-neuritic) speaks against tabes and often happens with syphilis of the brain.

Atherosclerosis ... Atrophy of the optic nerve in atherosclerosis occurs as a result of direct compression of the optic nerve by a sclerosed carotid artery or as a result of damage to the vessels feeding the optic nerve. Primary optic nerve atrophy develops more often, secondary atrophy much less often (after disc edema due to anterior ischemic neuropathy). Often there are sclerotic changes in the retinal vessels, but these changes are also characteristic of syphilis, hypertension and kidney disease.

Hypertonic disease ... Optic atrophy may be due to neuroretinopathy. This is a secondary disc atrophy with concomitant symptoms characteristic of hypertensive angioretinopathy.

In hypertension, optic atrophy may occur as an independent process not associated with changes in the retina and retinal vessels. In this case, atrophy develops due to damage to the peripheral neuron of the optic pathway (nerve, chiasm, tract) and has the character of primary atrophy.

Profuse bleeding ... After profuse bleeding (gastrointestinal, uterine), after a more or less long time, from several hours to 3-10 days, anterior ischemic neuropathy may develop, after which secondary atrophy of the optic nerve discs develops. The defeat is usually bilateral.

Leber's optic atrophy ... Familial hereditary atrophy of the optic nerves (Leber's disease) is observed in men aged 16-22 for several generations and is transmitted through the female line. The disease proceeds as bilateral retrobulbar neuritis, starting with a sharp drop in vision. A few months later, simple atrophy of the optic discs develops. Sometimes the entire nipple turns pale, sometimes only the temporal halves. There is usually no complete blindness. Some authors believe that Leber's atrophy is a consequence of optochiasmal arachnoiditis. The type of inheritance is recessive, linked to the X chromosome.

Hereditary infantile optic atrophy ... Children 2-14 years old are ill. Simple atrophy of the optic nerves gradually develops with temporal disc pallor, less often the nipple. Often, high visual acuity remains, and there is never blindness in both eyes. Central scotomas often occur in the field of view of both eyes. Color perception is usually impaired, and more by blue than by red and green. The type of inheritance is dominant, that is, the disease is transmitted from sick fathers and sick mothers to both sons and daughters.

Diseases and deformities of the bones of the skull ... In early childhood, with a tower-like skull and Cruson's disease (craniofacial dysostosis), congestive nipples may develop, after which secondary atrophy of the optic discs of both eyes develops.

Treatment principles

Treatment of patients with optic nerve atrophy is carried out taking into account its etiology. Patients with optic nerve atrophy, which developed due to compression of the peripheral neuron of the visual pathway by the intracranial process, require neurosurgical treatment.

To improve the blood supply to the optic nerve use vasodilators, vitamin preparations, biogenic stimulants, neuroprotectors, infusion of hypertonic solutions. Perhaps the use of oxygen therapy, blood transfusions, the use of heparin. In the absence of contraindications, physiotherapy is used: ultrasound in the open eye and endonasal drug electrophoresis of vasodilators, vitamin preparations, lekozyme (papain), lidase; use electrical and magnetostimulation of the optic nerves.

Forecast

Prediction of optic nerve atrophy always serious... In some cases, you can count on the preservation of vision. With developed atrophy, the prognosis is poor. Treatment of patients with optic nerve atrophy, whose visual acuity was less than 0.01 for several years, is ineffective.

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Atrophy of the optic nerve is a condition in which there is a partial or complete destruction of nerve fibers and their replacement with dense connective tissue elements.

Causes and provoking factors

The following factors can lead to optic nerve atrophy:

It should be noted that in more than 20% of cases, it is still not possible to determine the cause of optic nerve atrophy.

Classification

Depending on the time of appearance optic atrophy is:

• Acquired;
• Congenital, or hereditary.

By the mechanism of occurrence optic atrophy is divided into two types:

• Primary... It occurs in a healthy eye and is caused, as a rule, by a violation of microcirculation and nerve nutrition. It is divided into ascending (retinal cells are affected) and descending (optic nerve fibers are directly damaged);
• Secondary... Occurs against the background of eye diseases.

Glaucomatous optic atrophy is isolated separately.... As you know, this disease is accompanied by an increase in the numbers of intraocular pressure. As a result, the ethmoid plate is gradually destroyed - the anatomical structure through which the optic nerve enters the cranial cavity. A characteristic feature of glaucomatous atrophy is that it retains vision for a long time.

Depending on the preservation of visual functions atrophy happens:

• Full when a person absolutely does not perceive light stimuli;
• Partial, at which separate areas of the visual fields are preserved.

Symptoms of optic nerve atrophy

The clinical picture of optic nerve atrophy depends on the type and extent of damage to the nerve structures.

Atrophy is accompanied by a gradual narrowing of the visual fields and a decrease in visual acuity... As the disease progresses, it becomes difficult for a person to distinguish colors. With partial atrophy of the optic nerve, scotomas appear -.

Almost all patients report deterioration of vision at twilight and in poor artificial light.

Features of the disease in children

If there is congenital atrophy, then it begins to manifest itself from the first months of a baby's life. Parents notice that the child does not follow toys, does not recognize loved ones. This indicates a pronounced decrease in visual acuity. It happens that the disease is accompanied by total blindness.

Older children may complain of headaches, the appearance of dark or black areas in the field of vision. Almost everyone has difficulty recognizing colors.

Unfortunately, congenital atrophy of the optic nerve in a child is almost impossible to correct... However, the earlier the child is examined by a specialist, the more chances there are to stop the development of the disease.

Diagnosis of the disease

Fundus ophthalmoscopy plays a key role in the diagnosis. This is a fairly simple and affordable method that allows you to reliably establish a diagnosis.

If a person has primary atrophy, the doctor sees in the fundus blanching of the optic nerve head, as well as narrowing of the blood vessels. Secondary atrophy is also accompanied by disc pallor, but there will be vasodilatation caused by concomitant diseases. The boundaries of the disc are vague, the presence of punctate hemorrhages on the retina is possible.

Compare the fundus of a healthy person and a person with atrophy:

For a comprehensive diagnosis, the following methods are also used:

• Measurement of intraocular pressure (tonometry);
• Perimetry (assessment of visual fields);
• Plain X-ray of the skull (with suspicion of trauma or tumor-like formations);
• Fluorescent angiography (allows you to assess the patency of blood vessels);
• Doppler ultrasound (used when there is a suspicion of blockage of the internal carotid artery);
• Computed tomography or magnetic resonance imaging.

Often, to clarify the diagnosis, consultation of a neurologist, rheumatologist, traumatologist or neurosurgeon is required.

Treatment of optic nerve atrophy

Treatment of optic nerve atrophy is not possible

Unfortunately, to date, not a single doctor has been able to cure optic nerve atrophy. It is not for nothing that there is an opinion in the world that nerve cells cannot be restored. Therefore, the main goal of treatment is to preserve the surviving nerve fibers and prevent them from atrophy. At the same time, it is extremely important not to waste time. First of all, it is necessary to establish what caused the disease, and to start treating concomitant pathology. This is especially true for the drug correction of diabetes mellitus and hypertension.

In general, provide the functioning of the optic nerve can be done in two ways: with the help of surgical intervention and conservative methods (medication and physiotherapy).

Conservative treatment

In complex treatment, depending on the doctor's indications, the following groups of drugs are used:

Physiotherapeutic methods of treatment show good results, such as acupuncture, laser stimulation, electrophoresis, magnetotherapy, electrical stimulation.

Surgical intervention

Surgical treatment of optic nerve atrophy is indicated mainly in the presence of tumor-like neoplasms that somehow affect the optic nerve. Surgical tactics are also used in the case of anomalies in the development of the eye and some ophthalmic diseases.

Partial optic atrophy is a simpler form of atrophy in which fibers that are responsible for the accuracy of image transmission to the brain are affected. As a rule, the fibers begin to die off, after which they are replaced by connective tissue. And it, in turn, cannot replace the function of the fibers, therefore, there is a decrease in vision and field. There are only 2 forms of optic nerve atrophy. It is partial and complete.

Full death of fibers is meant completely, which inevitably leads to blindness. Unlike the full form, with a partial one, only a small part of the fibers dies, but this is also fraught with complications. Therefore, it is extremely important to timely detect atrophy and treat it. It is worth noting that the partial one is manifested by a slight weakening of sharpness and a significant loss of the ability to see color shades.

Initially, you need to understand how information about the image is transmitted to the visual part of the brain. It turns out that when a picture is perceived, a light signal appears, which passes through the retina and enters the brain through the optic nerve. It would seem that everything is simple, but the nerve has an excessively huge number of fibers, and each of them is responsible for a certain area. If there is a problem of death, then this light signal arrives in an altered pathological form, as a result of which vision is impaired.

what causes the disease

Partial optic nerve atrophy causes:

1. Compression of the optic nerve by various growths or tumors.
2. Retinal pathologies.
3. Glaucoma.
4. Inflammation in the nerve.
5. Myopia.
6. Brain pathology.
7. Infectious manifestations: encephalitis, brain abscess, meningitis, arachnoiditis.
8. Sclerosis.
9. Atherosclerosis.
10. Hypertension.
11. Heredity.
12. Poisoning with chemicals, alcohol.
13. Pathology of the nervous system, heart and blood vessels.
14. Injury.

Signs of a partial form of the disease

You need to know that usually with this disease, two organs are affected simultaneously, but with varying degrees (initially). The severity of the disease in total is 4. As a rule, the weaker the degree, the fewer symptoms are expressed. With the course of the disease, the symptoms intensify and aggravate. So, partial atrophy of the optic nerves in both eyes symptoms:

1. Decreased visibility.
2. When the eyes move, the patient experiences pain.
3. Disappearance of lateral vision due to narrowing of the visual field. And later it may fall out altogether.
4. The appearance of dark spots in the eyes, which are characterized as blind.

Treatment of a partial type of nerve atrophy

Unlike the full form, partial atrophy of the optic nerve is still treatable. It is aimed at stopping pathological changes in tissues directly in the optic nerve. In this case, the necessity is the preservation of what is still left in a healthy functional form. It is almost impossible to restore those fibers that have already turned into connective tissue, but even without treatment it is impossible. Otherwise, the pathology will progress, and this will lead to complete blindness.

As a rule, initially the treatment is applied conservatively. Drugs are selected that improve the blood supply to the nerve of the visual apparatus, accelerate metabolic processes throughout the body at the cell level, dilate blood vessels, biostimulating drugs and multivitamins. Thanks to such medicines, nutrition and saturation with useful substances of the optic organ is produced, the swelling of the nerve decreases, the inflammatory process is eliminated, which leads to the stimulation of healthy fibers.

In more complex cases, or if drug therapy has not yielded a positive result, a surgical method of treatment is used. Here, first of all, the cause of the disease is eliminated, in order to avoid further development. Physiotherapy is recommended in combination with the above two methods. This can be laser correction, electrical stimulation, exposure to the affected organ with magnetic beams, electrophoresis and even oxygen therapy.

Treatment depending on the cause

Therapy always depends on the cause of the pathology. For example:

1. With partial atrophy of the optic nerve, acquired due to disorders of the vascular system, vasoactive drugs and antioxidant agents are used. It can be Sermion, Cavinton and Tanakan, as well as Mexidop, Mildronat and Emoxipin.
2. If the disease has appeared due to disorders of the nervous system, then nootropic and fermenotropic drugs are used. For example, "Actovegin", Nootropil "," Sopkoseril "," Wobenzym "and" Phpogenzym ".
3. In case of toxic partial atrophy, not only vasoactive, nootropic agents are used, but also detoxification and peptide drugs.
4. In case of descending atrophy of a partial form, bioregulatory therapy with the use of drugs such as Cortexin and Epithalamin is indicated.
5. If the disease has arisen against the background of genetic inheritance, trauma or inflammation, then cytomedins ("Cortexin" or "Retinals") are used.

Partial optic nerve atrophy: Disability is assumed in the same way as in the case of complete atrophy. But in this case, group 3 is used if there is a 2 degree of severity of the disease. In this case, a weakened visualization of objects of an average degree should be present. To obtain other groups of disabilities, there must be indicators characteristic of complete atrophy.

How children are treated

With partial atrophy of the optic nerve in children, treatment is almost identical to that for adults. Also, the goal is to inhibit the progression and death of fibers. They nourish the nerve without fail, saturate it with oxygen. The drugs can be administered either by drop or by injection. Electrophoresis, oxygen therapy and ultrasound procedures are always used.