| Part I Clinical Research on Ophthalmic Manifestation in aneurysm of anterior circulationBackground:Blood flow of brain comes from arteria carotis interna and arteria vertebralis, and arteria carotis interna system and vertebral basilar system were called anterior circulation and posterior cerebral circulation.anterior circulation supplies 70% blood flow of brain, and posterior cerebral supplies 30% blood flow of brain.Arteria carotis interna and it"s branch is adjacent to visual pathway, oculomotor nerve, abducent nerve and trochlear nerve. Therefore, aneurysms of anterior circulation were often result in severe ocular motility disorders. Some Aneurysm of internal carotid artery and it's branchs could be manifested in ocular region. With development of technology and neuron-ophthalmology, ophthalmologists pay more attention to ophthalmopathy about intracranial aneurysm. Nevertheless, seldome reserchments were studied detailly. Aneurysm of internal carotid artery could result in oppression of optic nerve and function impairment of cranial nerves. So, we analysised characteristics of ocular region caused by aneurysms of anterior circulation, and summarized mechanism of ophthalmopathy caused by aneurysm of anterior circulation, and provide accurate evidence for early diagnosis in clinical work.Aim:1. To study characteristics of ophthalmopathy caused by aneurysm of anterior circulation.2. To study main position and size of aneurysm companied with ophthalmopathy.3. To study position of aneurysm of segment of C1, C2,C3,C4 and C5 campanied with various ophthalmopathy.4. To analysis infrequent ophthalmopathy caused by aneurysm of anterior circulation.Methods:We analyzed retrospectively clinical data of patients with aneurysm that had reffed to ophthalmology department of PLA General Hospital frome Dec. 2001 to Mar. 2010. All patients were examined routinely in ophthalmology. Aneurysm of anterior circulation was divided to C1, C2, C3, C4 and C5 segment. Aneurysm were devided into microaneurysm, small aneurysm, moderate aneurysm, large aneurysm and giant aneurysm.Diagnosis: all patients were diagnosed by DAS and (or) MAV.Results:Location of anterior aneurysm companied with ophthalmopathy:25 cases(55.56%) were aneurysm of intracalvarium in all 45 cases of anterior circulation aneurysm. 9 cases(20%) were aneurysm of C1 segment,and 9 cases(20%) were aneurysm of C2 segment, and 7 cases(15.56%) were aneurysm of C3 segment.19 cases(42.22%) were in C4 segment.In 9 cases of aneurysm of C1 segment, 6 cases were in origination of arteria communicating artery.Size of aneurysm: In all 45 cases, 29 cases(64.4%) were giant aneurysm; 9 cases(20%) were large aneurysm.Giant aneurysm was the most frequent type in aneurysm of anterior circulation companied with ophthalmopathy, and lage aneurysm is the second frequent type. Multiple anterior cirulation aneurysm: In all 45 cases, 11 cases(24.4%) were multiple anterior circulation aneurysm. General situation of manifestation in ophthalmology in aneurysm of anteriorcirculation: In all 45 cases,22 cases(48.9%)were companied with visual loss caused by aneurysm; In these cases, 8 cases(36.4%) were in C2 segment and 7 cases(31.9%) were in C4 segment. Visual field defect caused by anterior aneurysm:15 cases were tested with visual field, and 3 cases were companied with bitemporal hemianopia, and homonymous hemianopia in opposite side and nasal visual field defect are in 1 cases respectively. 11 cases were companied with irregular visual field defect.Paralysis of oculomotor nerve and abducent nerve caused by aneurysm of anterior circulation: In all cases, 27 cases(60%) were companied with ocular motility disorders.25 cases(55.6%) were companied with oculomotor paralysis.Ocular manifestation of anterior circulation aneurysm in different location:Ocular manifestation of aneurysm in C4(cavernous sinus) segment: In all 45 cases, 19 cases(42.2%) were aneurysm in C4 segment.15 cases(78.9%) were giant aneurysm.10 case(52.6%) were manifested with oculomotor paralysis companied with abducens paralysis.5 cases were oculomotor paralysis and 4 cases were abducens paralysis.6 case(31.6%) were companied with severe visual loss.Ocular manifestation of aneurysm in C3 segment: In all 45 cases, 7 cases were anerysm in C3 segment and were all in origination of ophthalmic artery. 7 cases(57.1%) were companied with severe visual loss in affected side. Ocular manifestation of aneurysm in C4 segment: 9 cases were aneurysm in C2 segment, and in these cases, 4 cases were giant aneurysm. All 9 cases were companied with severe visual loss.Ocular manifestation of aneurysm in C5 segmentOcular manifestation of aneurysm in posterior communicating artery: In all cases, 9 cases were aneurysm in posterior communicating artery. Among these cases, 5 cases were aneurysm in origination of posterior communicating artery, and 4 cases were moderate aneurysm.Ocular manifestation: all 5 cases were companied with oculomotor paralysis, and corectasis were observed in 4 cases, and 1 case was not companied with abnormality in pupil.Ocular manifestation in anterior communicating artery: 2 cases were aneurysm in anterior communicating artery. 1 case was giant aneurysm and 1 case were lage aneurysm. The two cases were companied with evere visual loss all, and pallor in optic disc were observed in the two cases. bitemporal hemianopia were tested and anterior communicating artery was diagnosised through DSA.Ophthalmic artery aneurysm discovered by chance for other ophthalmic diseaseDiagnosis of aneurysm of anterior circulation aneurysm: all cases were made final diagnosis through DSA and (or) MRA.Treatment: all cases were operated with aneurysm incarcerated operation or endoaneurysm filling or operation of ic-ec bypass.Conclusion:1. Main ophthalmic manifestation of anterior circulation aneurysm were visual loss, defect of field vision, cranial nerve paralysis. Cranial nerve paralysis is the most frequent manifestation, and visual loss in affected side is the second frequent manifestation.2. Aneurysm in intracranial section(C1+C2+C3) and C2 section (cavernous sinus section) is frequent location, and intracranial section is the most common location.3. Giant aneurysm and large aneurysm in more frequent in anterior circulation aneurysm companied with ophthalmic manifestation. In all anterior circulation aneurysm companied with oculomotor nerve palsy, C4 segment and C1 segment were more frequent.4. Aneurysm in C4 segment companied ophthalmic manifestation were giant aneurysm mainly. Cranial nerve palsy and visual loss in affected side were main ophthalmic manifestation, and cranial nerve palsy in affected side is the most frequent manifestation. Oculomotor nerve palsy companied with abducens nerve palsy is more frequent.5. Severe visual loss and visual field defect were main ophthalmic manifestation aneurysm of C2 and C2 segment.6. Oculomotor nerve paralysis companied with acute mydriasis in affected side in main ophthalmic manifestation in posterior communicating aneurysms in C1 segment, and severe visual loss is rare. Anterior communicating artery aneurysm in C1 segment could oppress anterior horn of optic chiasma, and result in severe visual defect and visual field defect in affected side or double side.7. Internal carotid artery ophthalmic arterysegmental aneurysm may be result in central artery occlusion, but relevant clinical evidence is difficult to find. Part II Clinical Research on Ophthalmic Manifestation in cranial venous sinus thrombosisCerebral vein sinus thrombosis (CVST) is a kind of special cerebrovascular disease, and It's age of onset is early. Youngs, middle-aged people and female in perinatal period are more more susceptible for CVST. CVST is easy to be misdiagnosed and with rapid clinical course, some literature reported that 50 percent of CVST was misdiagnosed. CVST was always companied with symptom of intracranial hypertension. So, patients with CVST were companied with bilateral papilloedema and visual loss. Patients with CVST were often reffed to ophthalmology. Ophthalmologist were short of understanding on CVST, so doctors were easy to make misdiagnosis on CVST. Patients with CVST were delay to diagnosis and treat. Clinical researchment on ophthalmic manifestation of CVST is less, and ealier studies on CVST were made by neurologist, and study on ophthalmic manifestation was not detailed study. Our study collected cases of CVST, and summarize missed diagnosis and misdiagnosis in ophthalmology. We evaluated degree of abducens nerve palsy due to CVST, and provide information for ophthalmologist and neurologist to make early diagnosis and treatment for CVST.Aim:1 To study characteristics of ophthalmopathy caused by CVST2 To study characteristics of abducens nerve palsy in CVST3 To study main position of CVST of CVST companied with ophthalmic manifestation and methods of diagnosis for CVST.4 To analysis misdiagnosis and missed diagnosis of CVST in ophtha- lmology.Methods:We analyzed retrospectively clinical data of 36 patients with CVST that had reffed to ophthalmology department of PLA General Hospital from Dec. 2006 to Mar. 2010. Male patients were 11, and female patients were 25. All patients were examined routinely in ophthalmology, and iagnosis of CVST was made through DSA and (or) MRV.Results:1.Among the 36 cases,34 patients were companied with optic disc and binocular visual loss. 13 cases(36.1%) were companied with ambiopia. 9 cases were binocular abducens nerve palsy, and 4 cases were unilateral abducens nerve palsy. 7 cases companied with abducens nerve palsy were tested by synoptophore. Extend of abducens nerve palsy was from 8 degree to 15 degree, and average 13 degree.2. Among all cases, 25 cases were companied with thrombosis of lateral sinus thrombosis, and 13 cases were companied with thrombosis of superior sagittal sinus thromboses, and 8 cases were companied with thrombosis of sigmoid sinus;sinus sigmoideus. 23 cases were made final diagnosis of CVST by DSA, and 11 cases were done by MRA, and 1 case was done by MRI.3.Among the 19 cases,all patients were companied with optic disc edema. Binocular visual acuity of 18 cases were decreased. 7 cases were companied with ambiopia. Amaurosis fugax was in 1 case. 10 cases were made misdiagnoses of bilateral neuropapillitis(one case was made second diagnosis of bilateral abducens nerve paralysis), 5 cases were made misdiagnoses of bilateral papillovasculitis, and ischemic optic neuropathy, Vogt-Koyanagi-Harada syndrome companied with oculomotor nerve palsy, Leber's optic neuropathy and abducens nerve palsy were made misdiagnosis in one case each.Conclusion:1. Patients with CVST are often companied with sight decline , diplopia and Opticdiscedema and other ocular manifestation.2. More than 30 percent of patients with CVST were companied with abducens nerve palsy, and degree of abducens nerve palsy were mild palsy. 3. CVST is easy to be made misdiagnoses of neuropapillitis, papillovasculitis, ischemic optic neuropathy and other diseases or be made missed diagnosis.4.Patients with CVST are often companied with headache and other manifestation of nervous system. MRI and MRV could be the first means to make diagnosis of CVST finally, and DSA is the most accurate method to make diagnosis of CVST.
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