Visual pathway lesions


The visual pathway consists of structures that carry visual information from the retina to the brain. Lesions in that pathway cause a variety of visual field defects. In the visual system of human eye, the visual information processed by retinal photoreceptor cells travel in the following way:
Retina→Optic nerve→Optic chiasm →Optic tract→Lateral geniculate nucleus→Optic radiation→Primary and secondary visual cortices.
The type of field defect can help localize where the lesion is located.

Optic nerve lesions

The optic nerve, also known as cranial nerve II, extends from the optic disc to the optic chiasma. Lesions in optic nerve causes visual field defects and blindness.

Causes

Causes of optic nerve lesions include optic atrophy, optic neuropathy, head injury etc.

Signs and symptoms

The optic chiasm, or optic chiasma is the part of the brain where both optic nerves cross. It is located at the bottom of the brain immediately inferior to the hypothalamus. Signs and symptoms associated with optic chiasm lesions are also known as chiasmal syndrome. Chiasmal syndrome has been classified into three types; anterior, middle and posterior chiasmal syndromes. Another type is lateral chiasmal syndrome.

Causes

Causes of chiasmal syndromes may be classified into intrinsic and extrinsic forms. Intrinsic causes are due to thickening of the chiasm itself and extrinsic implies compression by another structure. Other less common causes of chiasmal syndrome are metabolic, toxic, traumatic or infectious in nature. Compression of the optic chiasm is associated with pituitary adenoma, Craniopharyngioma, Meningioma etc.

Signs and symptoms

The optic tract is a continuation of the optic nerve that relays information from the optic chiasm to the ipsilateral lateral geniculate nucleus, pretectal nuclei, and superior colliculus. The optic tract represents the first stage in the visual pathway in which visual information is transferred in a homonymous nature. Main characteristic feature of lesion involving whole optic tract is homonymous hemianopsia. A lesion in the left optic tract will cause right-sided homonymous hemianopsia, while a lesion in the right optic tract will cause left-sided homonymous hemianopsia.

Causes

The optic tract syndrome is characterized by a contralateral, incongruous homonymous hemianopia, contralateral relative afferent pupillary defect, and optic atrophy due to retrograde axonal degeneration. Causes of optic tract lesions are also classified into intrinsic and extrinsic forms. Intrinsic lesions include demyelinating diseases and infarction. Such lesions produce optic tract syndrome type II. Extrinsic or compressive lesions are caused by pituitary craniopharyngioma, tumours of optic thalamus. Other causes include syphilitic meningitis, gumma and tubercular meningitis etc.

Signs and symptoms

The lateral geniculate nucleus is the nucleus in the thalamus that receives visual information from the retina and sends it to the visual cortex via optic radiations. A lesion of this nucleus produces moderately to completely congruent visual field defects. Isolated lesions of the lateral geniculate nucleus are rare, it may be diagnosed by distinctive patterns of visual field loss.

Causes

compression may cause LGN degeneration. Lesions affecting the anterior or lateral choroidal arteries may affect the lateral geniculate nucleus.

Signs and symptoms

The optic radiation are axons from the neurons in the lateral geniculate nucleus to the primary visual cortex.

Causes

Middle cerebral artery and posterior cerebral artery infarcts may affect the optic radiations, and can cause quadrantanopias.

Signs ans symptoms

The visual cortex located in the occipital lobe of the brain is that part of the cerebral cortex which processes visual information. Cortical blindness refers to any partial or complete visual deficit that is caused by damage to the visual cortex in the occipital lobe. Unilateral lesions can lead to homonymous hemianopias and scotomas. Bilateral lesions can cause complete cortical blindness and can sometimes be accompanied by a condition called Anton-Babinski syndrome.

Causes

Stroke, head injury or gunshot injuries, infection, eclampsia, encephalitis, meningitis, medications, and hyperammonemia can cause cortical blindness.

Signs and symptoms

Visual field testing

Measurements of visual field defects can be done by visual field testing. It can be performed by various methods, including confrontation technique, amsler grid, tangent screen, kinetic perimetry, or static perimetry. Cost common is automated perimetry.

Confrontation test

Confrontation visual field testing is a simple and quick visual field assessing method. A confrontational field test requires little or no special equipment and can be performed in any room, which is well illuminated.
Patient sitting straight in front of the examiner, is asked look directly at the examiner’s eye during the test. The target eye should be the one directly across from the patient’s eye. When the patient’s right eye is being tested, closing the other eye, patient is instructed to look directly at the examiners left eye. Examiner closes his/her left eye, and then conduct finger movements, bringing his/her fingers or any other into your visual field from the sides. Since the test is basically comparison of the patient's visual field with the examiner's visual field, it is not an accurate measument of visual field.

Perimetry

Modern computerized perimeters like humphrey field analyser give more comprehensive and accurate reports than finger testing methods.

Magnetic resonance imaging

MRI of the brain and orbit helps to find the exact site of a lesion.

Computed tomography scan

CT scan is also used for investigating cause of visual pathway lesions.

Treatment

Tumours and other compressive lesions could often present with visual impairment and/or visual field defects. Careful clinical assessment could aid in accurate diagnosis of the cause of the visual field defect and loss of vision. Compressive lesions of the visual pathway, especially lesions affecting optic nerve require a multi-disciplinary approach involving neurosurgeon, physician as well as the ophthalmologist. Treatment is given according to the cause.