optic disc , various abnormalities of optic disc,

1. Optic Disc: Anatomy,
Variants, Unusual discs
Kathleen B. Digre, MD
Professor Neurology, Ophthalmology

2. THE OPHTHALMOSCOPE

3. DIRECT
OPHTHALMOSCOPY
• Jan Purkinje 1823
• Hermann von
Helmholtz 1851
• Hand held
ophthalmoscope
• Direct up-right
image

4. Dials of the Ophthalmoscope

5. RED-FREE FILTER (GREEN
LIGHT)
450 nm monochromatic light
nerve fiber layer
optic nerve drusen

6. OTHER DIALS
• Used for measuring
lesion size
• Looking for the
center of fixation

7. OTHER DIALS: SLIT BEAM

8. The wheel has lenses of power

9. Steps to Direct Ophthalmoscopy
• Dimly lit room
• Dilating drops
• Patient fixates distant
target
• Align yourself
• Red reflex
• Dial in

10. The layers you will go
through to see the optic disc

11. THE OPTIC NERVE

12. THE NORMAL DISC
• The disc is 1.62 mm
or 1 million fibers
• Central retinal
artery and vein
• Lamina Cribrosa
• The optic cup

13. WHAT YOU SHOULD OBSERVE IN EVERYONE

14. The Normal Disc Appearance

16. NO CUP
0.3 CUP
0.1
CUP
0.7 CUP
0.9 CUP

17. NERVE
FIBER
LAYER

18. NORMAL NERVE FIBER LAYER

19. NERVE FIBER
LAYER:
TOTAL LOSS

20. NERVE FIBER LAYER: WEDGE
LOSS

21. NERVE FIBER: RAKE DEFECTS

22. VASCULAR
SUPPLY TO THE
GLOBE AND DISC
TWO MAJOR SOURCES by
way of the ophthalmic
artery+
•Posterior Ciliary arteries
•Central retinal artery

23. BLOOD SUPPLY TO THE DISC
is from the posterior ciliary arteries
The posterior ciliary
arteries supply the disc,
the choroid and the
retinal pigment epithelium

24. BLOOD SUPPLY TO THE
DISC
The central retinal artery
supplies the retina

25. CILIORETINAL
ARTERY
• Present in about
32% of patients
• Enters separate
from the CRA
• Occlusion with
swollen nerve =
Temporal arteritis
• Spared in CRAO

26. Tasman and Brown, Congenital Anomalies of
The optic disc. 1983; 82
straight
Hook from disc
Hook edge disc margin
Hook from juxtapapillary region

27. DISCS THAT ARE ONLY CILIORETINAL ARTERIES?
Barroso LH, Hoyt WF, Narahara M. Can the arterial supply of the retina in man be exclusively
cilioretinal? J Neuroophthalmol. 1994 Jun;14(2):87-90.
WHAT SYSTEMIC ANOMALY SHOULD YOU LOOK FOR?
A: Renal dysplasia: Papillo-renal syndrome

28. VASCULAR
VARIATIONS
TRIFURCATIONS
CONGENITAL
TORTUOSITY

29. VENOUS
DRAINAGE OF
THE GLOBE

30. VENOUS ANOMALIES
Edge Veins of Kraupa- All venous
drainage—one vein
Barroso L, Hoyt WF, Narahara M. Disc edge
veins of Kraupa: rare exit anomalies of the
retinal vein. BJO 1992;76:442-3

31. Congenital
Acquired after
CRVO
Other conditions?
Optic meningioma
CRVO
Glaucoma
Glioma
Sarcoid
Chronic papilledema
Congenital
Retino-choroidal
collaterals

32. PAPILLEDEMA
FEATURES OF TRUE
SWELLING
• Hyperemia
• Swelling of nerve fibers
• Elevation disc margin
• Maintenance of cup if
present
• Loss of venous pulse
INCIDENTAL FINDINGS
• Hemorrhages
• Retinal folds
• Nerve Fiber Layer infarcts

33. FEATURES DISTINGUISH TRUE PAPILLEDEMA
FROM PSEUDOPAPILLEDMA
PAPILLEDEMA
• Physiologic cup present
• Vessels are normal
• Hyperemia
• Diffuse elevation
• Retinal veins dilated
• Exudates
• No SVP
PSEUDOPAPILLEDEMA
• Absent cup
• Vessels arise from center
• Disc color normal
• Elevation irregular
• Veins not dilated
• No exudates
• SVP

34. VENOUS PULSATIONS

35. “Normal” variations

36. MYOPIC DISC

37. HYPEROPIC DISCS

38. LITTLE RED DISCS
• Frequently confused
for papilledema
• Discs “at risk”
• Frequently hyperopic
• May be hypoplastic

39. Megallopapilla
Rarely associated with what condition? Optic n glioma

40. MYELINATED NERVE FIBERS
• Developmental
abnormality when
the myelin goes
beyond the lamina
cribrosa
• Feathered edge
• Usually no effect on
vision

41. What is left behind and how the eye
is made affects the appearance of
the disc
Bergmeister
Papilla

42. Pre-papillary arterial
convolutions
Retinal arterioles NOT a-v;
Multiple arteriolar loops
No visual loss unless they bleed
Pre-papillary arterial
loop

43. TILTED DISCS

45. Tilted discs: Visual field cuts
(refractable)

46. OPTIC DISC DRUSEN
An inherited anomaly that is often
confused with papilledema

47. VISIBLE DRUSEN

48. BURIED DRUSEN

49. IMAGING DRUSEN
AUTOFLUORESCENCE
CT APPEARANCE
(not MRI)

50. OPTIC DISC HYPOPLASIA confused
with optic atrophy
• Very common optic
disc anomaly
• The double ring sign
• Vision is affected
• Usually seen in
children of diabetic
mothers
• Look for pituitary
dysfunction

51. Hypoplasia
OPTIC NERVE HYPOPLASIA

52. Optic Nerve Hypoplasia:
(not DeMorsiere’s Syndrome)
(optic n hypoplasia, (absent septum pellucidum) and dwarfism)
• Vision variable
• Seen in drug use
alcohol
phenytoin
• Maternal infections
• Diabetes
Think midline
Defects with
hypopituitarism
Agensis of corpus
Collosum; absent septum pellucidum
Thinning/absence of cc
small chiasm
Pituitary may be absent
Look for DI, GH deficiency,
Hypothyroidism,
hypo-corticoidism,
Growth retardation

53. Segmental hypoplasia
TOPLESS
DISCS
What association?
Diabetes

54. From
Unoki, Ohba, Hoyt,
Br J Ophth
2002; 86; 910-14

55. COLOBOMA MEANS GAP
Failure of closure of the embryonic fissure

56. OPTIC DISC COLOBOMA
Usually inferior
Disc may appear enlarged
Pigmentary changes around defect common
Think cardiovascular, CNS defects, nasopharyngeal

57. What associations
To consider?
Trans-sphenoidal
Encephalocele

58. COLOBOMAS
• Amblyopia
• Trans-sphenoidal and other encephaloceles
• WHEN COLOBOMAS ARE BILATERAL THINK:
CHARGE = COLOBOMA +
– Heart
– Atresia Choanae
– Retarded Growth and Development
– Genital Hypoplasia
– Ear Anomalies

59. Double discs?

60. OPTIC DISC COLOBOMA: CT

61. MORNING GLORY DISC
White central tissue
Excavated nerve; halo surrounds
Vessels radial Basal encephalocele
Vascular dysgenesis:
Moya MoyaWHAT ASSOCIATIONS?

63. OPTIC DISC PITS
What complications
Can occur from Pits?
Serous Detachments

64. VIEW THE DISC WITH
CONFIDENCE
• IDENTIFY NORMAL STRUCTURES—
differentiate variants from disc swelling
or atrophy
• Look for disc anomalies
• Know anomalies that have systemic
associations

65. NOVEL URL
http://NOVEL.utah.edu

66. 1. 50 yo man with headache--
transient obscurations in the right
eye
2. What is the disc abnormality?

67. 2. 9 yo asymptomatic boy referred
for papilledema by optometrist
3. Is this papilledema?

68. 3. Headache and visual loss in
the right eye
6. What is the disc anomaly?

69. 4. Two different patients--what
is this?
7. Name this anomaly

70. 5. Which disc is abnormal?
6. Name the disc defect?
7. What structure will you look for on an MRI?
8. In a child, what test would you order?

71. 9. What is the disc anomaly?
10. What tests will you order?

72. 11. WHAT IS THE ANOMALY?
12-14: List 3 causes

73. 15. What artery is occluded?

74. 16. Name the defect
17. Name a condition associated
with the defect

75. 18. Name the defect
19 What condition associated with
defect?

76. 20. NAME A RESOURCE
WHERE YOU CAN LOOK AT A
LOT OF DISC Anomalies!