CONGESTIVE NIPPLE (synonym congestive disk) — noninflammatory hypostasis of a nipple (disk, PNA) optic nerve.
In 1910. F. Schieck offered the so-called transport theory of a pathogeny 3. page. Chic connected development 3. page with a delay of outflow of the intercellular lymph from an eyeglobe on perineural spaces of an axial yarn of an optic nerve caused by counter current of the liquid directing from the intershell spaces under the influence of the increased intracranial pressure. However pilot studies did not confirm existence of the message between perineural spaces of an axial bunch of an optic nerve and the intershell spaces surrounding a nerve. The Retentsionny theory of Rem (S. of Behr, 1912) proceeds from idea of a delay of the liquid flowing from an eyeglobe in the bone channel at an exit of a nerve from an eye-socket in a head cavity. However a research of all course of a nerve in the bone channel by means of a trakhiskopichesky technique of M. A. Showed the baron (1949) that any prelum of an optic nerve in the bone channel at 3. the page does not occur, the intershell spaces of an optic nerve remain widely open on all course of the bone channel. The optic nerve throughout is surrounded with the cavities filled with the liquid which is under the influence of intracranial pressure. At build-up of pressure processes of fabric exchange in an optic nerve and its blood supply are broken that can lead to changes, oftalmoskopichesk expressed a picture 3. page
Among origins 3. pages the greatest value have diseases of a brain, at the same time tumors of a brain are on the first place. In development 3. pages matter also inflammatory granulomas (tuberculomas, gummas), parasitic cysts, abscesses, an inflammation of a meninx and an edema of a brain. 3. the page can be observed at diseases of kidneys, a hypertension and some diseases of blood, at a tower-shaped skull, tumors of an eye-socket, the getting wounds of an eyeglobe which are followed by sharp decrease in intraocular pressure.
The pathological anatomy
At a pathoanatomical research of eyes attracts attention significant increase in the sizes of an optic disk which sometimes eminates over the level of a retina on 2 mm and more. Because of increase in diameter of a disk the tissue of a retina surrounding it is displaced. At microscopic examination the expressed noninflammatory hypostasis of a disk and trunk of an optic nerve is noted. Nerve fibrils are moved apart by the liquid which accumulated between them getting also between gliozny fibers and connective tissue layers on a disk. Blood vessels of a disk and a retina are considerably expanded. In places there are hemorrhages. The connective tissue trellised plate is quite often dugoobrazno stuck out under pressure of the bulked-up fabrics (tsvetn. fig. 1 — 4). Gradually hypostasis of a disk regresses, nerve fibrils are replaced with neogenic gliozny fabric. Sometimes there is a progressing atrophy of nerve fibrils.
Fig. 4. Scheme of blood supply of an optic nerve: 1 — a retina; 2 — a choroid; 3 — a sclera; 4 — a back short ciliary artery; 5 — a firm meninx of an optic nerve; in — a soft meninx of an optic nerve; 7 — a visual opening; 8 — eye artery; 9 — arteries of a soft meninx of an optic nerve; 10 — the central artery of a retina; 11 — a branch of the central artery of a retina to a trunk of an optic nerve; 12 — a vascular circle of an optic nerve; 13 — the lower temporal arteriole of a retina; 14 — an upper temporal arteriole of a retina.
3. the page usually happens bilateral, in initial stages does not cause explicit visual frustration therefore quite often it is revealed accidentally at inspection of the persons who addressed the oculist in other occasion. Quite often it is the patients directed by the therapist or the neuropathologist for a research of an eyeground in connection with uncertain complaints to frequent headaches or to sudden misting of sight at a sharp postural change of a body (e.g., at a bystry rising from a bed).
At long existence 3. pages at the patient quite often arise these or those visual frustration — disturbances of fields of vision, formation of scotomas that speaks about some local impact on a trunk of an optic nerve (or pressure upon a certain site of a trunk of a nerve a basal tumor or elements of a brain displaced by it, or some limited basal inflammatory process). If visual frustration are connected with the come atrophy of nerve fibrils, they can have irreversible character.
the Diagnosis is made on the basis of data of an oftalmoskopiya and functional researches of an eye.
Oftalmoskopichesky picture in the expressed cases 3. the page happens quite characteristic (tsvetn. fig. 6 — 10). The stushevannost of an optic disk, an illegibility of its borders, sharply expressed crimpiness of blood vessels and expansion of their caliber is noted. In development 3. pages in the field of an optic disk quite often appear hemorrhages; vessels of a retina, especially venules, are sharply expanded, form wide loops. Tissue of a retina around an optic disk is sharply edematous what it indicates change of its color and a smazannost of the drawing. In the expressed stage protrusion in a vitreous, a sharp papilledema with the expressed hemorrhages and considerable expansion and crimpiness of veins of a retina is noted. In late stages peripapillary hypostasis is less expressed, the optic disk is represented pale, with uneven, as if corroded edges.
Oftalmokhromoskopichesky research allows to catch displays of hypostasis very much early. Refraktometrichesky and kampimetrichesky methods give the chance to perform measurements as degrees of a vystoyaniye 3. page forward, in a vitreous, and expansion of its diameter (see. Kampimetriya , Refractometry ). Great value as in specification of the diagnosis 3. the page, and in studying of its pathogeny and clinic has a method of a fluorescent angiography of a retina (see. Oftalmoskopiya ), the course allowing to track and a condition of all blood vessels of a retina up to a capillary network. At suspicion on 3. pages are obligatory nevrol, inspection of the patient and rentgenol, a research of a skull.
The differential diagnosis
At establishment of the diagnosis 3. the page, especially at early stages, arises need of carrying out the differential diagnosis with an optic neuritis. Functional researches of eyes facilitate diagnosis. So at neuritis already in an early stage there are visual frustration (decrease in visual acuity, emergence of scotomas, restriction of a field of vision) whereas at 3. pages visual functions long remain normal.
On the basis of an oftalmoskopichesky picture 3. the page sometimes can be taken for a pseudo-congestive nipple which is observed at the anomaly of development of an optic disk and vessels going on a surface of a disk or at druses of a disk (see. Eye, pathology ). Existence of atypical vessels in the field of an optic disk at anomalies, a hilly type of a disk with scalloped edges and not changed vessels at druses of a disk also testify in favor of a pseudo-congestive nipple. Druzes are especially well visible at an oftalmokhromoskopiya in red light. At persons of advanced and senile age 3. the page can be taken for the ischemic papilledema arising in connection with an obliteration of the vessels feeding an optic nerve. However lack of an arc reflex about a disk at ischemic hypostasis allows to make the correct diagnosis.
Sometimes 3. the page should be differentiated with impassability of the central artery and vein of a retina. Existence in macular area of a retina of a bright red spot of a round or oval form at impassability of the central artery of a retina and a large number of the hemorrhages extending radiarno on the course of branchings of venules of a retina helps with diagnosis. Besides, at impassability of the central artery and vein of a retina sudden loss of sight that is not observed at 3 is noted. page. At gipermetrop of edge of an optic disk can
sometimes be represented indistinctly konturirovanny that can also give a reason to suspect beginning 3. page. Such gipermetropa often complain of persistent headaches (see. Asthenopia ), which it is possible to charge to increase in intracranial pressure. However stability of an oftalmoskopichesky picture of an optic disk in this case allows to exclude 3. the page
Regression of the phenomena of stagnation in an optic nerve can be reached by treatment of a basic disease.
After normalization of intracranial pressure (as a result of decompressive operation or an oncotomy, etc.) a vystoyaniye of a disk usually decreases soon, but diameter its long time remains increased. Changes of an eyeground can disappear completely in early stages. At elimination of the reason which caused 3. pages, borders of an optic disk and in later terms remain uneven, its blood vessels are narrowed why the disk becomes pale, anemic. At the same time decrease in visual acuity is noted. It is long existing 3. the page can lead to an atrophy of an optic nerve and falloff of visual functions.
Bibliography: Averbakh M. I. The main forms of changes of an optic nerve, M., 1944; Bing R. and Brückner R. Mozg and an eye, lane with it., L., 1959; Wolves V. V. and Nikitin I. M. Eye symptomatology in eponima, L., 1972, bibliogr.; Samoylov A. Ya. Experience of dynamic studying of congestive nipples at tumors of a brain, in book: Vopr, neyrooftalm., under the editorship of E. Zh. Tron?, page 31, L., 1958; Tronas E. Zh. Diseases of a visual way, page 57, L., 1968, bibliogr.; With about g a n D. Neurology of the visual system, Springfield, 1967, bibliogr.; Medical ophthalmology, ed. by F. C. Rose, L., 19 76; Neuroophthalmologie, hrsg. v. R. Sachsenweger, Lpz., 1975, Bibliogr.
A. Ya. Samoylov.