Neutrophthalmology
Neuro-Ophthalmology is the field of ophthalmology that concerns the diseases of the nerves that connect the eyes to the brain. Dr. Nikolaos Trakos treats diseases that affect optic nerves and the brain: optic neuritis, ischemic optic neuropathy, episodes of transient loss of vision, strokes with vision loss or diplopia, migraine with ocular symptoms, tumors in the central nervous system with involvement of optic nerves or optic chiasm, multiple sclerosis, myasthenia gravis, mitochondrial diseases, diplopia and strabismus, nystagmus, temporal arteritis, myopathies of the sedative muscles, idiopathic intracranial hypertension, as well as diseases of the oculomotor brain nerves leading to disorders of ocular movements.
How is the diagnostic approach to a neuro-ophthalmological disease done?
Collaboration with other disciplines such as neurology, rheumatology, neurosurgery and pathology may be required. Neuro-ophthalmological diseases can lead to permanent vision loss (e.g. Temporal arteritis, Rapidly Idiopathic intracranial hypertension (Fulminant IIH) and potentially fatal (e.g. Cerebral Aneurysms, Acute Horner syndrome due to the dissection of the carotid artery, Pituitary apoplexy).
Neuro-ocular diseases can be classified into two broad categories depending on the part of the optic system that is affected:
A) Diseases of the Adductor system (Afferent visual pathway)
B) Diseases of the Ductile System (Efferent visual pathway).
The Adductor optical path transmits visual information from the optic nerve to the brain. Diseases affecting the Adductor system include visual neuropathies (e.g. Non-arterial Optic Neuropathy, Temporal arteritis, Multiple sclerosis, Neuromyelitis Optica Spectrum Disease Spectrum Disease Associated Diseases, Optic Nerve Glioma, Optic Nerve Sheath Meningioma, Leber (congenital optic neuropathy), Inflammatory and infectious processes, Tumors in the Optic Chiasm region (e.g. Pituitary adenoma, craniopharyngioma, meningioma) and strokes.
The Abductor optical path is responsible for the coordinated movement of both eyes and the size of the pupil. Many conditions can affect the Abductor pathway, including nerve palsies (e.g., palsy of the common motor nerve on an aneurysm of the posterior anastomotic artery), Horner syndrome, myasthenia, thyroid eye disease, Dorsal Midbrain syndrome, Multiple Sclerosis, adaptation spasm, Miller Fisher syndrome, skew deviation and Progressive Hyperpyremic Paralysis (Progressive Supranuclear Palsy). Manifestations of Abduction Pathway dysfunction may include drooping eyelid, anisocory, external and internal ophthalmoplegia, tranuclear ophthalmoplegia, nystagmus, gaze palsy, diplopia and strabismus.
Dr. Nikolaos Trakos makes the diagnosis between common ocular cases and cases that can potentially lead to blindness and death. For example, cases with an enlarged cup to disk ratio may be incorrectly diagnosed as low-pressure glaucoma, when in fact they are due to compression optic neuropathy due to a brain tumor. Often, these cases do not give a correct diagnosis, leading to a potentially life-threatening delay or never becoming a diagnosis.
The main tool of Dr. Nikolaos Trakos for the correct diagnosis of his patient is the detailed clinical examination in combination with the high technology available, and the carrying out of hematological or imaging tests to further investigate the patient’s symptoms.
What is optic neuritis?
Optic neuritis is an inflammation of the optic nerve. In it, there is a loss of myelin, a substance that surrounds the optic nerve, resulting in its disruption of function. A percentage of patients with optic neuritis may develop multiple sclerosis in the future, which is why Dr. Nikolaos Trakos may request an MRI of the orbital – brain to determine the risk.
The condition is manifested by:
– sudden, one-sided decrease in vision
– color disorders
– visual field disorders
– with characteristic pain during eye movements
The majority of patients are women with a mean age of 32 years.
Vision usually begins to improve after 2 to 4 weeks of the onset of symptoms of optic neuritis. Depending on the severity of the appearance and the imaging findings, Dr. Trakos can proceed to treatment of the patient with intravenous corticosteroids, followed by oral administration with gradual dose reduction, according to the most modern therapeutic models applied.
Progress in neuro-ophthalmology and immunology has helped to distinguish, classify and better address the spectrum of Neuromyelitis Optica spectrum disorders (NMOSD), with major diseases:
-Neuromyelitis Optica (NMO) and
– anti-Myelin Oligodendrocyte glycoprotein antibody disease (MOG)
In the past, many cases of patients with very low vision or involvement of both eyes were considered and treated as atypical optic neuritis, but it turned out that they belonged to the NMOSD spectrum.
This scientific development has led to a better understanding of the clinical picture of the type of optic neuritis, so that the diagnosis is made more accurately. In addition, more specific and highly effective treatments (steroids, plasmapheresis, immunoglobulins) have been developed to restore the vision of these patients with optic neuritis, which would otherwise be rapidly led to blindness, paralysis or even loss of life.
An essential element of any surgical procedure, especially cosmetic surgery, is providing the patient with sufficient time for information.
What is idiopathic intracranial hypertension?
Idiopathic intracranial hypertension is a disease manifested by headaches, transient loss of vision when changing head position or bending, tinnitus or other intracranial sounds, diplopia (due to flare nerve), decrease of vision and visual field disorders.
In order to make the diagnosis, Dr. Nikolaos Trakos will examine the fundus of the eye, will conduct a visual field test with the most modern machinery available at the Eye Center Ye-Lid, and will investigate with MRI evidence that supports the diagnosis. In some cases, a lumbar puncture may be required. Because the disease can lead to permanent vision loss and complete blindness, careful monitoring of patients is critical for monitoring of visual function and treatment modification (medication or surgical intervention [optic nerve sheath fenestration, shunting]).
What is nystagmus?
Nystagmus is an oscillation of the eyes, which is rhythmic and biphasic. The oscillation can be horizontal. Pathological nystagmus is caused by damage, either to the vestibular system (peripheral or central), or to the visual path. The presence of certain types of nystagmus has a special diagnostic value, as in the case of Downbeat nystagmus (rapid down phase), often associated with drugs such as lithium or with diseases and tumors in the cervical-medullary junction region (e.g. Chiari malformation).
What is arterial-type anterior ischemic optic neuropathy?
The anterior ischemic arteritic optic neuropathy (AAION) is the ocular manifestation of temporal arteritis–GCA and is an emergency condition. It is a sudden necrosis of the optic nerve due to inflammation, which causes ischemia through narrowing of the lumen of the vessels. It is due to inflammation of the vessels, the so-called vasculitis.
Patients present with a sudden, severe decrease in vision, usually, in one eye and then in the other. Symptoms such as transient loss of vision and diplopia are typically preceded. Many sufferers experience systemic symptoms including manifestations of Polymyalgia Rheumatica (arthralgia, shoulder pain), headaches, fatigue during chewing or speaking (intermittent jaw lameness), fever, fatigue, anorexia and weight loss. Temporal arteritis usually affects over 70 years of age, and more often women.
The likelihood of improved vision in the affected eye is limited, even with direct intervention. However, immediate therapeutic intervention (intravenous steroids) is necessary in high-suspicion cases in order to reduce the possibility of an eye infection, as the likelihood of the second eye being affected within days or weeks exceeds 70% (unfortunately, even under timely treatment, vision can be completely lost in the other eye).
In addition, treatment is required to treat systemic symptoms and protect the patient’s life, as temporal arteritis can lead to cardiovascular complications, such as aortic aneurysm, stroke and myocardial infarction. The diagnosis can be confirmed by a biopsy of the temporal artery within 7 to 10 days of starting cortisone.
Why choose Dr. Trakos?
Dr. Trakos’ contribution to the field of anterior segment and cataract surgery, as well as to the treatment of vision problems, has changed the lives of many people by improving their sight and quality of life.
What is non-arterial anterior ischemic optic neuropathy (NAION)?
Non-arterial anterior ischemic optic neuropathy (NAION) is the most common cause of sudden, painless vision loss in people over the age of 50.
Possible etiology is insufficient blood flow in the posterior radial arteries leading to ischemia and necrosis of the retrolaminar part of the optic nerve. NAION patients are usually between 60-70 years old and present with sudden decrease in vision ranging from mild to severe.
The main risk factors are hypertension, diabetes, elevated cholesterol, as well as nocturnal hypotension, an anatomically congested optic nerve, sleep apnea (although recent data doubt a direct correlation) and the use of drugs for erectile dysfunction (Viagra). 30% of patients will experience further deterioration of visual acuity, 30% will remain stationary, while 30% will improve. The risk of involvement of the bowel eye varies from 15% to 30% in different studies.
Elimination of risk factors appears to be currently the realistic approach to avoid involvement of the other eye, as cortisone administration, either therapeutically or preventively, has not been widely accepted clinically and the literature does not favor it. Another approach adopts administration for prevention and generally cardiovascular protection of the patient of a low dose of aspirin.
It is worth noting that NAION infestation of an eye appears to act as a protective for a new episode for the same eye, as the likelihood of reinvasion in the future is very low.
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