Vitreopapillary Traction

Vitreopapillary traction. Note the mild peripheral obscuration of retinal vessels in both eyes with relative preservation of the optic disc margins.

Optical coherence tomography of vitreopapillary traction (same patient). Bilateral vitreopapillary traction noted.

Fluorescein angiography of vitreopapillary traction (same patient). Note the mild focal leakage seen in both eyes (perhaps slightly more prominent in the left eye).

Image credit: Houle E, Miller NR. Bilateral vitreopapillary traction demonstrated by optical coherence tomography mistaken for papilledema. Case Rep Ophthalmol Med 2012;2012:682659. doi: 10.1155/2012/682659. Available online. Used for educational purposes.

Vitreopapillary Traction

Vitreopapillary traction. A, Photograph of the right optic nerve shows disc elevation, blurred margins, and obscuration of nasal vessels. B, Transverse optical coherence tomography reveals peripapillary vitreous adhesion and traction, resulting in elevation of the optic disc and peripapillary retina.

Image credit: Simonett JM, Winges KM. Vitreopapillary traction detected by optical coherence tomography. JAMA Ophthalmol 2018;136(5):e180727. doi: 10.1001/jamaophthalmol.2018.0727. Available online. Used for educational purposes.

Vitreopapillary Traction

Vitreopapillary traction. The condensation of vitreous over the optic nerve can cause the optic nerve to look blurred, and the traction itself can result in elevation of the optic nerve and blur the edges of the optic nerve.

Image credit: Courtesy of Alex P. Hunyor, M.D. Retina Image Bank. American Society of Retina Specialists. Available online. Used for educational purposes.

Optic Disc Drusen

Buried optic disc drusen.

A. Left optic disc demonstrating fullness but no obvious drusen.

B. B-scan ultrasonography of patient’s left eye reveals hyperechoic, high signal characteristic of optic disc drusen (see arrow).

Image credit: American Academy of Ophthalmology. Used with permission for educational purposes.

Optic Disc Drusen

Optic disc drusen.

Optic disc drusen are hyaline or calcified deposits within the optic nerve head. They may be visible at the optic nerve head or buried. Nasal visual field defects and other glaucoma-like visual field defects may be present, though most visual field defects are asymptomatic.

There are many imaging modalities that help visualize optic nerve drusen, including B-scan ultrasonography (C), autofluorescence (D), and CT (E).

A. Fundus photograph of optic disc drusen, showing blurred disc margin with scalloped edge, refractile bodies on the disc surface and at the superior pole, mild pallor, and no obscuration of retinal blood vessels.

B. Visual field patterns confirmed the presence of a nasal step produced by drusen involving the right disc.

C. B-scan ultrasonogram, demonstrating focal, highly reflective (due to calcification) elevation within the optic disc (arrow), which persists when the gain is decreased

D. Preinjection fundus photograph demonstrating autofluorescence (arrow).

E. CT scan of the orbits. Calcified optic disc drusen are visible bilaterally at the posterior globe–optic nerve junction (arrows).

Part A courtesy of Steven A. Newman, MD; part B courtesy of Michael S. Lee, MD; parts C, E courtesy of Anthony C. Arnold, MD; part D courtesy of Hal Shaw, MD.

Image credit: Basic and Clinical Science Course, Section 5: Neuro-Ophthalmology. San Francisco: American Academy of Ophthalmology, 2018-2019: 142. Used with permission for educational purposes.

Optic Disc Drusen

Optic disc drusen.

Optic disc drusen are hyaline and calcified nodules within the optic nerve head. They may be visible on the surface of the optic nerve or buried, mimicking optic nerve edema (pseudoedema). Drusen may autofluoresce, which may help reveal optic disc drusen.

Image credit: American Academy of Ophthalmology. Used with permission for educational purposes.

Pharmacologic Testing for Horner Syndrome (video): Lecture from Dr. Andrew Lee, M.D.

Video credit: Lee AG. Pharmacologic Testing for Horner Syndrome. Video. YouTube. Available online. Accessed 02-27-2019.

Dilation Lag (video)

Two examples of dilation lag (Horner's syndrome). In the first example, the right pupil dilates much faster than the left pupil when the light is turned out. In the second example, the left pupil dilates much faster than the right pupil when the light is turned out.

Video credit: Digre KB, Jacobson D, Balhorn R. Dilation Lag. Video. [Neuro-Ophthalmology Virtual Education Library: NOVEL Web Site]. 2005. Available online. Accessed 02-27-2019.

Hydroxyamphetamine Test

Hydroxyamphetamine test for Horner syndrome.

A. Before drops administered (suspected right Horner syndrome).

B. After drops administered. Note the dilation of both pupils. This indicates an intact 3rd-order, postganglionic neuron and localizes the lesion to the 1st-order (central) or 2nd-order (preganglionic) neuron.

Image credit: Modified from clinical images courtesy of Lanning B. Kline, M.D. American Academy of Ophthalmology. Used with permission for educational purposes.

Apraclonidine Test

Apraclonidine test for Horner syndrome.

A. Before drops administered (suspected left Horner syndrome).

B. After drops administered. Note the slight “reversal of anisocoria” in the left eye and the resolution of ptosis.

Image credit: Kanagalingam S, Miller NR. Eye Brain 2015;7:35-46. Available online. Used under the Creative Commons Attribution - Non Commercial (unported, v3.0) License.

Cocaine Test

Cocaine test for Horner syndrome.

A. Before drops administered (suspected right Horner syndrome).

B. After drops administered. Note that there is some pupil dilation in the right eye, but the amount of anisocoria is ≥1 mm.

Image credit: Kanagalingam S, Miller NR. Eye Brain 2015;7:35-46. Available online. Used under the Creative Commons Attribution - Non Commercial (unported, v3.0) License.