Transcript Grand Rounds

Grand Rounds Conference
Janelle Fassbender, MD, PhD
University of Louisville
Department of Ophthalmology and Visual Sciences
July 18, 2014
Subjective
CC: 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: None
Meds: lamotrigine, oxcarbazine, lisdexamfetamine
Allergies: NKDA
Objective
BCVA:
Pupils:
IOP:
EOM:
CVF:
OD
OS
20/25
20/25
5 to 3 mm OU, No RAPD
17
17
Full
Full
Superonasal
Superotemporal
defect
defect
Objective
Slit Lamp Exam:
External/Lids
Conjunctiva/Sclera
Cornea
Anterior Chamber
Iris
Lens
Vitreous
Normal OU
Normal OU
Clear OU
Deep, quiet OU
Normal OU
Clear OU
Normal OU
Dilated Fundus Exam
OD:
*Inferior camera artifact
OS:
Visual Fields (24-2)
OS:
OD:
Left superior homonymous quandrantanopia
Pre-operative MRI Brain
Normal brain MRI
*Patient is rotated on table, yielding asymmetry between right and left lobes.
Post-operative MRI Brain
Anterior, 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 radiations
Diffusion tensor tractography –
Patient post-op
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%
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.

Visual cortex activity outside of scotoma
expected from automated perimetry.
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.
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