망막 conference Visual field defect 2012. 6.5 R3정현진/ Pf. 박영훈

Case I (F/69) C.C: visual field defect (bitemporal hemianopsia) 2011.1.24 C.C: visual field defect (bitemporal hemianopsia) onset) noticed several months ago (전안부파트에서 우안 백내장 수술 POD#9병일째 교정시력 나오지 않아 시행한 망막검사에서 R/O impending macular hole(OD)로 망막파트로 의뢰됨 ) DM/HBP(+/+) for 16yrs/for 27yrs insulin Tx. & po medi./po medi. Ocular op/trauma(+/-) 2011.1.13 Phaco+PCL(OD) by Pf.주천기 6390010

Ocular exam VA OD OD 0.32(N-C) OS 0.4 IOP OD/OS 10/16 mmHg EOM Straight at 1' position by ACT , No LOM(OU) Orbit No exophthalmos(OU) Lid OU No swellling Conj. OU not injected Cornea OU clear AC OU Deep& cell(-) Pupil OD round & nl sized, LR(+) OS round & nl sized, LR(+), RAPD(-/-) LensOD well positioned PCL OS mod. Cortical opacity c NS c PSCO Fd OU nl optic disc c flat post pole

Fd-photo(OU) OS sclerotic vessel R flat no MH

M-OCT(OU) OD OS

ICG(OD->OS) ICG를 왜하셨는지 생각해야?

VF 24-2

Cue list Impression Plan Bitemporal hemianopsia Ant. Segment, funduns, M-OCT, ICG -> neative findings R/O brain tumor R/O brain infarction NS consultation Impression Plan

Brain MRI T2 axial T1 GD coronal T1 sagittal Brain MRI에서 sella 및 suprasellar region에 걸쳐 5.8 x4 x 5 cm 크기의 heterogeneously enhancing mass 관찰됨. 이 mass는 주로 sella region 및 suprasellar region을 involvement하고 있고 일부 planum sphenoidale involvement하고 있음. 또한 sella floor 을 뚫고 일부 sphenoid sinus에서도 관찰됨. Rt. internal carotid artery mass 의해 부분적인 encasement 보임. Rt. cavernous sinus로의 invasion이 의심됨. Mass는 Rt. optic chiasm에 닿아있고 optic nerves 및 3rd ventricle의 floor를 elevation 시키는 것으로 보여짐. Pituitary macroadenoma의 소견으로 보여짐.

Treatment 2011.4.4 EE-TSA with tumor removal  Bx. :pituitary Adenoma * 2011.3.18 Pituitary Hormone(TFT, ACTH, cortisol, prolatin, HGH) : WNL -> non-functioning pituitary ademona Endoscopic endonasal

POD# 7months S: 보이는 것이 좋아졌어요 VA OD 0.8 OS 0.63(N-C) IOP OD 19mmHg / OS 15mmHg ant. Segments: OS mod. Cortical opacity c NS c PSCO Fundus OU flat RNFL OCT(OU)

VF 24-2

Case II (M/39) C.C: decreased VA (OU) onset) noticed 2 months ago 2012.2.21 C.C: decreased VA (OU) onset) noticed 2 months ago PI : 한달전 부터 눈앞이 뿌옇게 보이고 초점이 맞지 않는 증상으로 을지병원 안과에서 시행한 검사에서 근시외 특이소견 보이지 않아 시야검사 권유받고 내원함. DM/HBP(-/+) for 3yrs po medi. Ocular op/trauma(-/-) Ishihara test: OD 21/21 OS 17/21 HRR OU WNL 25033843

Ocular exam VA OD 0.02(0.63 x -4.50Ds=-1.25Dc Ax180) OS 0.04(0.4 x -4.00Ds=-2.00Dc Ax180) IOP OD/OS 20/19 mmHg at 3:45 pm EOM Straight at 1' position by ACT , No LOM(OU) Orbit No exophthalmos(OU) Lid OU No swellling Conj. OU not injected Cornea OU clear AC OU Deep& cell(-) Pupil OD round & nl sized, LR(+) OS round & nl sized, LR(+), RAPD(-/-) Lens OU rl. Clear Fd OD CDR 0.4/0.4, nl optic disc c flat post pole OS CDR 0.4/0.4, nl optic disc c flat post pole Ishihara test: OD 21/21 OS 17/21 HRR OU WNL 손가락 말단의 비대 ? Acromegalic features

Fd-photo(OU) Fd CDR 0.4/0.4, nl optic disc c flat post pole

M-OCT OD OS

VF 24-2 Binocular temporal hemianopsia(OD<OS)

VEP VEP mild delayed P100 OU

ERG ERG WNL

Cue list Impression Plan Bitemporal hemianopsia Ant. Segment, funduns, M-OCT, ERG -> neative findings VEP : sl. P100 delay R/O brain tumor R/O brain infarction NS consultation Impression Plan

Brain MRI T2 axial T1 GD coronal T1 saggital Poorly enhancing sellar and suprasellar mass, r/o pituitary macroadenoma.(3.3x3x2.5cm) Compression of optic chiasm and Rt. cavernous sinus.

Plan 2012.4.25 EE-TSA Acromegaly feture, IGF-1 571.31 증가, glucose suppression test : positive finding -> GH producting pituitary ademoma 손가락 말단의 비대 ? Acromegalic features IGF-1 571.31로 증가 수술한달후 f/u예정 but 예약 없음 Glucose suppression test: positive

Case III (M/51) C.C: Amaursis fugax(for 10mins) & Lt. hemifield defect 2011.2.23 C.C: Amaursis fugax(for 10mins) & Lt. hemifield defect onset) noticed 1wk ago(2/16) PI : 1주일전 비행기 착륙시 발생한 양안 시력저하가 10분정도 지속되었다 호전 되었다가 좌측 바깥쪽이 보이지 않는 증상이 지속되어 local안과방문하여 시행한 검사에서 특이소견 보이지 않아 내원함. * Lt. leg tingling sensation(+) DM/HBP(-/-) Ocular op/trauma(-/-) 23657464 Amaursis fugax for 10min 비행기 착륙시 좌측 다리가 저린 증상 신경과검사 motor weakness뚜렷하지 않으나 DTR은 좌측에 항진됨, senory test에서 좌측 하지가 우측에 비해 pin prick test시 80%로 감소되어 있음 신경과 imp) Rt. PCA infarction c thalamic infarction, R/O post. Choroidal infarction Lt gazy envoked nystagmus-horizontal ECG상 A-fib Warfarin start TTE hypokinesia Digaitalization

Ocular exam VA OD 0.06(0.8 x -3.25Ds) OS 0.1(1.0 x -2.75Ds=-0.50Dc Ax110) IOP OD/OS 10/10 mmHg EOM Straight at 1' position by ACT , No LOM(OU) Orbit No exophthalmos(OU) Lid OU No swellling Conj. OU not injected Cornea OU clear AC OU Deep& cell(-) Pupil OD round & nl sized, LR(+) OS round & nl sized, LR(+), RAPD(-/-) Lens OU mild cortical opacity Fd OU nl optic disc c flat post pole

Fd-photo(OU)

VF24-2 Lt. Upper Homonymus quadrianopia

RNFL OCT(OU) 왜했을까?

Cue list Impression Plan VF :Ant. Lt. homonymous quadrianopsia Amaurosis fugax Ant. Seg : negative finding Fundus : negative finding R/O brain tumor R/O brain infarction NU consultation -> brain MRI irregular HB c murmur->cardioconsultation Impression Plan

Brain MRI T2 axial T1 GD sagittal T1 GD Axial T1 GD coronal Rt. occipital lobe 및 posterior medial temporal lobe에 T2-weighted image에서 high signal intensity의 infarction 있고 조영증강후 gyral enhancement 있어 subarachnoid stage infarction 보임. T1 GD Axial T1 GD coronal

Progression Anticoagulant Treatment 2011.4 CAG(1VD) PCI for LAD OS 2011.10 EP c RFCA d/t A.fib Binocular pain for 2months 번져 보여요

3months later VA OD 0.06(0.8 x -3.25Ds) OS 0.1(1.0 x -2.75Ds=-0.50Dc Ax110) IOP OD/OS 10/11 mmHg R flat O-BXL x 2(OU) Homologous LT. quadrianopsia

VF24-2 Improved VF defect

RNFL OCT(OU)

Review 망막 conference 2012. 5.22 R3정현진/ Pf. 박영훈 Neuroanatomy through clinical case 2012. 5.22 R3정현진/ Pf. 박영훈

Visual Pathways Lat. LGN Med. LGN Sup. radiation Inf. radiation

Normal Humphrey visual field Optic n.에는 photoreceptor가 없기 때문에 temporal field에 blind spot 은 normal 제일 밝은 빛을 못 보면 숫자 0, 숫자 높을수록 잘 보는 것 우측 상단의 gray scale은 왼쪽의 숫자들을 색으로 바꾼 것 좌측 하단의 total deviation은 연령 평균에 대비한 것 우측 하단의 pattern deviation은 국소적인 abnormality들을 강조해서 표현한 것

Interpreting a visual field

Ant. Visual Pathways Retina Optic disc -Macular lesion : central or paracentral defect -Most degenerative retinopathy (Retinitis pigmentosa) : pph or mid pph VF defect Optic disc Defect within the central 30 degree -arcuate defect -central or paracentral defect -centrocecal scotoma M. hole, contral scotoma R P goldman peripheral contriction bilt. Glaucomatous optic neuropathy: contral scotoma(OS)-severe constriction inferior arcuate defect(OD) bilateral optic atrophy d/t hereditary optic neuropathy  bilatearl centrocecal scotomas

Optic chasim

Junctional scotoma

Retrochiasmal Visual Pathways Controlateral homonymous hemianopia congruent incongruent

Retrochiasmal Visual Pathways Optic tract Contralateral RAPD(+) Nasal : temporal 53:47 Nasal retina는 반대쪽 optic tract에서 기원 Optic tract lesion의 반대쪽 눈에서 주로 RAPD가 관찰된다

Lateral Geniculate Nucleus From ICA Lat. Wedge of LGN -> Inf. radiation Choroidal artery의 Ischemic lesion인 경우 영역에 따라 두 패턴으로 나뉨 From PCA Med. Wedge of LGN -> Sup. radiation

Retrochiasmal Visual Pathways Optic Radiation

Retrochiasmal Visual Pathways Sup. fiber Inf. fiber

Retrochiasmal Visual Pathways Sup. fiber Pie in the floor Inf. fiber Pie in the sky

Retrochiasmal Visual Pathways Occipital lobe의 post. Tip은 MCA, PCA로부터 같이 dual blood supply

Retrochiasmal Visual Pathways Occipital Lobe: Sparing the Temporal Crescent Bilateral occipital lobe lesion Occipital lobe의 post. Tip은 MCA, PCA로부터 같이 dual blood supply