Thai J Ophthalmol Vol. Vol. 25 No. 1 January-June 2011 33 Acute Idiopathic Blind Spot Enlargement Syndrome Pisit Preechawat, M.D Virongrong Surushniti, M.D. Abstract Unilateral blind spot enlargement can occur as an isolated entity (acute idiopathic blind spot enlarge- ment) or in association with various chorioretinal diseases. The authors report four cases of acute idiopathic blind spot enlargement who presented with unilateral temporal scotoma. All cases had normal visual acuity and color vision. Optic disc edema was presented in 3 patients. There was no other ocular abnormality in all patients.Recovery of visual field occurred in all cases after treatment with a short course of systemic steroid. Thai J Ophthalmol 2011; January-June 25(1): 33-42. Case Report/√“¬ß“πºŸâªÉ«¬ Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University
Acute Idiopathic Blind Spot Enlargement Syndrome
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untitledThai J Ophthalmol Vol. Vol. 25 No. 1 January-June 2011 33
Acute Idiopathic Blind Spot Enlargement Syndrome
Pisit Preechawat, M.D Virongrong Surushniti, M.D.
Abstract Unilateral blind spot enlargement can occur as an isolated entity (acute idiopathic blind spot enlarge-
ment) or in association with various chorioretinal diseases. The authors report four cases of acute idiopathic blind spot enlargement who presented with unilateral temporal scotoma. All cases had normal visual acuity and color vision. Optic disc edema was presented in 3 patients. There was no other ocular abnormality in all patients.Recovery of visual field occurred in all cases after treatment with a short course of systemic steroid. Thai J Ophthalmol 2011; January-June 25(1): 33-42.
Case Report/√“¬ß“πºŸâªÉ«¬
Acute Idiopathic Blind Spot Enlargement Syndrome
Case Report/√“¬ß“πºŸâªÉ«¬
¿“§«‘™“®—°…ÿ«‘∑¬“ §≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
∫∑§—¥¬àÕ ¿“«–∑’Ë¡’°“√¢¬“¬¢π“¥¢Õß blind spot “¡“√∂‡°‘¥¢÷Èπ‰¥â‚¥¬‰¡à∑√“∫ “‡Àμÿ ‡√’¬°«à“acute idiopathic blind spot
enlargement À√◊Õæ∫√à«¡°—∫‚√§¢ÕߧÕ√Õ¬¥åÀ√◊Õ®Õμ“∫“ߪ√–‡¿∑ √“¬ß“πºŸâªÉ«¬ 4 √“¬∑’Ë¡“¥â«¬Õ“°“√¡Õ߉¡à™—¥„π∫√‘‡«≥
temporal ¢Õßμ“¥â“π„¥¥â“πÀπ÷Ëß ·≈–‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ acute idiopathic blind spot enlargement æ∫«à“ºŸâªÉ«¬
∑ÿ°√“¬¡’√–¥—∫ “¬μ“·≈–°“√¡Õ߇ÀÁπ ’ª°μ‘ μ√«®æ∫«à“¡’°“√∫«¡¢Õߢ—È«ª√– “∑μ“„πºŸâªÉ«¬ 3 √“¬ ‚¥¬‰¡àæ∫«à“¡’§«“¡
º‘¥ª°μ‘¢Õßμ“ à«πÕ◊Ëπ√à«¡¥â«¬ ¿“¬À≈—ß°“√√—°…“¥â«¬¬“ ‡μ’¬√Õ¬¥å„π√–¬– —Èπ æ∫«à“≈“π “¬μ“¢ÕߺŸâªÉ«¬∑ÿ°√“¬ “¡“√∂
øóôπμ—«°≈—∫¡“‡ªìπª°μ‘‰¥â ®—°…ÿ‡«™ “√ 2554; ¡°√“§¡-¡‘∂ÿπ“¬π 25(1): 33-42.
«‘√ߧå√Õß ÿ√—™π‘μ‘, æ.∫.
æ‘»‘…∞å ª√’™“«—≤πå, æ.∫.
35Acute Idiopathic Blind Spot Enlargement Syndrome
∫∑π” Blind spot enlargement syndrome ‡ªìπ°≈ÿà¡
‚√§∑’Ë¡’§«“¡º‘¥ª°μ‘¢Õß peripapillary retina ´÷Ëßæ∫‰¥â ‰¡à ∫àÕ¬ ·≈–¬—߉¡à∑√“∫°≈‰°„π°“√‡°‘¥‚√§∑’Ë™—¥‡®π ‡π◊ËÕß®“° °“√«‘π‘®©—¬¿“«–π’È ¬—߉¡à¡’ criteria ·≈– classification ∑’Ë ·πàπÕπ ¥—ßπ—Èπ®“°√“¬ß“π∑’˺à“π¡“®÷ßæ∫«à“¡’§«“¡À≈“° À≈“¬¢ÕߺŸâªÉ«¬∑’ˉ¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ‚√§π’È Õ¬Ÿà¡“°1-7
Miller1 ·≈– Rosenberg2 √“¬ß“πºŸâªÉ«¬ „πªï §.». 1977 ·≈– 1984 ∑—ÈßÀ¡¥ 10 √“¬ ∑’Ëμ√«®æ∫«à“¡’ unilateral disc edema ‚¥¬‰¡àæ∫«à“¡’ increased intracranial pressure √à«¡¥â«¬ ·≈–‰¡à¡’ optic nerve dysfunction ¬°‡«âπ blind spot enlargement ®“°°“√μ√«®≈“π “¬μ“ ¿“«–π’È∂Ÿ°‡√’¬°«à“ çthe big blind spot syndromeé
„πªï §.». 1988 Fletcher3 √“¬ß“πºŸâªÉ«¬ 5 √“¬∑’Ë¡“ ¥â«¬ unilateral blind spot enlargement with normal visual acuity ·μàμà“ß°—∫√“¬ß“π°àÕπÀπâ“π’Èμ√ß∑’Ë«à“ºŸâªÉ«¬ ∑ÿ°√“¬‰¡à¡’ optic disc edema √à«¡¥â«¬ ¿“«–π’È∂Ÿ°‡√’¬°«à“ acute idiopathic blind spot enlargement (AIBSE) syndrome
®“°À≈—°∞“π∑’Ë¡’„π‡«≈“μàÕ¡“ ‡™◊ËÕ«à“ AIBSE·≈– big blind spot syndrome ‡ªìπ‚√§‡¥’¬«°—π ·≈–Õ“®‡ªìπ
√Ÿª∑’Ë 1.1 Humphrey visual field 30-2 ¢ÕߺŸâªÉ«¬√“¬∑’Ë 1 · ¥ß temporal visual field defect „πμ“¥â“π¢«“
spectrum Àπ÷Ëß ¢Õß‚√§„π°≈ÿࡇ¥’¬«°—∫chorioretinitis∫“ß Õ¬à“ß ‡™àπ multiple evanescent white dot syndrome (MEWDS), acute zonal occult outer retinopathy (AZOOR), multifocal choroiditis·≈– acute macular neuroretinopathy
√“¬ß“π©∫—∫π’È¢Õ𔇠πÕºŸâªÉ«¬ 4 √“¬∑’Ë¡“¥â«¬Õ“°“√ ¢Õß unilateral temporal scotoma ·≈–¡’≈—°…≥–∑“ß §≈‘π‘°∑’ˇ¢â“‰¥â°—∫¿“«– AIBSE
√“¬ß“πºŸâªÉ«¬√“¬∑’Ë 1 ºŸâªÉ«¬À≠‘߉∑¬Õ“¬ÿ 18 ªï ¡“μ√«®¥â«¬Õ“°“√μ“¢«“
¡—«¡Õ߇ÀÁπ¿“æ∫“ß à«π¢“¥À“¬‰ª ¡“π“π 3 «—π ‰¡à¡’ Õ“°“√ª«¥»’√…–À√◊Õª«¥μ“ ‰¡à¡’‰¢â·≈–Õ“°“√º‘¥ª°μ‘Õ◊ËπÊ
√–¥—∫ “¬μ“ 20/20 ∑—Èß 2 ¢â“ß anterior segment ª°μ‘ pupil ¢π“¥ 3 ¡¡ ‡∑à“°—π∑—Èß 2 ¥â“π μ√«®æ∫ rela- tive afferent pupillary defect (RAPD) ¢π“¥ 0.3 log unit „πμ“¥â“π¢«“ º≈°“√μ√«®®Õ쓪°μ‘·≈–°“√¡Õ߇ÀÁπ ’ (color vision) ª°μ‘∑—Èß 2 ¢â“ß
º≈°“√μ√«®≈“π “¬μ“ Humphrey visual field (HVF) 30-2 æ∫«à“¡’ right temporal visual field defect (√Ÿª∑’Ë 1.1) Magnetic resonance imaging (MRI) ¢Õß
36 æ‘»‘…∞å ª√’™“«—≤πå, «‘√ߧå√Õß ÿ√—™π‘μ‘ Vol. 25 No. 1 January-June 2011
√Ÿª∑’Ë 1.2 Multifocal ERG trace array (·∂«∫π) ·≈– topographic map (·∂«≈à“ß) ¢ÕߺŸâªÉ«¬√“¬∑’Ë 1 · ¥ß„Àâ‡ÀÁπ∂÷ߧ«“¡ º‘¥ª°μ‘¢Õß macula μ“¢«“ («ß°≈¡) „πμ”·Àπàß∑’Ë Õ¥§≈âÕß°—∫≈“𠓬μ“∑’˺‘¥ª°μ‘ (¥Ÿ‡ª√’¬∫‡∑’¬∫°—∫μ“´â“¬∑’˪°μ‘) (√Ÿª ’∑⓬‡≈à¡)
√Ÿª∑’Ë 1.3 Humphrey visual field 30-2 μ“¢«“¢ÕߺŸâªÉ«¬√“¬∑’Ë 1 ∑’Ë√–¬–‡«≈“ 10 «—π (A) 3 —ª¥“Àå (B) 7 —ª¥“Àå (C) ·≈– 4 ‡¥◊Õπ (D) · ¥ß„Àâ‡ÀÁπ∂÷ß°“√‡ª≈’ˬπ·ª≈ß∑’Ë¥’¢÷Èπμ“¡≈”¥—∫
‡∫â“μ“·≈– ¡Õß ‰¡àæ∫«à“¡’§«“¡º‘¥ª°μ‘¢Õß optic nerve signal ·≈–‰¡àæ∫√Õ¬‚√§„π ¡Õß Õ¬à“߉√°Áμ“¡ºŸâªÉ«¬‰¥â √—∫°“√«‘π‘®©—¬„π‡∫◊ÈÕßμâπ«à“‡ªìπ right retrobulbar optic neuropathy ‚¥¬§‘¥∂÷ß “‡Àμÿ„π°≈ÿà¡ optic neuritis ¡“° ∑’Ë ÿ¥ º≈°“√μ√«®‡≈◊Õ¥ complete blood count (CBC)
erythrocyte sedimentation rate (ESR) ·≈– anti-nuclear antibody (ANA) ª°μ‘
ºŸâªÉ«¬‰¥â√—∫°“√√—°…“¥â«¬ methylprednisolone ©’¥ ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” «—π≈– 1 °√—¡‡ªìπ‡«≈“ 3 «—π·≈– √—∫ª√–∑“π prednisolone μàÕ „π¢π“¥ 60 ¡‘≈≈‘°√—¡μàÕ«—π
37Acute Idiopathic Blind Spot Enlargement Syndrome
Õß —ª¥“ÀåÀ≈—ß°“√√—°…“ ºŸâªÉ«¬‰¥â√—∫°“√μ√«® pattern visual evoked potential (VEP) º≈°“√μ√«®æ∫ «à“ P1 amplitude ·≈– latency ª°μ‘∑—Èß 2 ¢â“ß º≈°“√ μ√«® multifocal electroretinogram (mfERG) æ∫«à“¡’ °“√≈¥≈ߢÕß mfERG amplitude „πμ”·Àπàß∑’Ë Õ¥§≈âÕß °—∫≈“𠓬μ“∑’˺‘¥ª°μ‘ (√Ÿª∑’Ë 1.2) ´÷Ëß®“°º≈°“√μ√«®¥—ß °≈à“« · ¥ß„Àâ‡ÀÁπ«à“ “‡Àμÿ¢Õß temporal visual field defect„πºŸâªÉ«¬√“¬π’È ‰¡à‰¥â‡°‘¥®“° ganglion cell À√◊Õ nerve fiber defect ·μà‡°‘¥®“°§«“¡º‘¥ª°μ‘¢Õß outer retina ºŸâªÉ«¬‰¥â√—∫°“√«‘π‘®©—¬„π∑⓬∑’Ë ÿ¥«à“‡ªìπ AIBSE ·≈–§àÕ¬Ê ≈¥¢π“¥¬“ prednisolone ≈ß®πÀ¬ÿ¥‰¥â„π√–¬–‡«≈“ 6 —ª¥“Àå
μ√«®≈“𠓬μ“æ∫≈—°…≥– temporal visual filed defect ¡’¢π“¥‡≈Á°≈ß·≈–À¥·§∫≈߇√◊Ëլʇ¢â“À“μ”·Àπàß ¢Õß blind spot
√“¬ß“πºŸâªÉ«¬√“¬∑’Ë 2 ºŸâªÉ«¬À≠‘߉∑¬Õ“¬ÿ 34 ªï ªØ‘‡ ∏‚√§ª√–®”μ—«¡“
μ√«®¥â«¬Õ“°“√μ“¢«“§àլʡ—«≈ß¡“π“π 1 ‡¥◊Õπ ∫“ß §√—È߇ÀÁπ· ß«“∫∫√‘‡«≥À“ßμ“ ·μà‰¡à¡’Õ“°“√º‘¥ª°μ‘Õ◊ËπÊ
√–¥—∫ “¬μ“ 20/25 „πμ“¢«“ ·≈– 20/20 „πμ“ ´â“¬ºŸâªÉ«¬¡’ “¬μ“ —Èπ -6.00 diopters ∑—Èß Õߢâ“ß anterior segment ª°μ‘ pupil ¢π“¥ 3 ¡¡. ‡∑à“°—π∑—Èß 2 ¥â“π μ√«® æ∫ RAPD „πμ“¥â“π¢«“ º≈°“√μ√«®®Õμ“æ∫«à“¡’ disc edema „πμ“¥â“π¢«“ (√Ÿª∑’Ë 2.1A) °“√¡Õ߇ÀÁπ ’ ª°μ‘∑—Èß 2 ¢â“ß
º≈°“√μ√«®≈“π “¬μ“ HVF 30-2 æ∫«à“¡’ right temporal visual field defect (√Ÿª∑’Ë 2.2) ‚¥¬≈—°…≥– ≈“𠓬μ“∑’˺‘¥ª°μ‘¡’®ÿ¥»Ÿπ¬å°≈“ß∑’Ëμ”·Àπàß blind spot º≈°“√μ√«® fundus fluorescein angiogram (FFA) æ∫ «à“¡’ fluorescein leakage ∑’Ëμ”·Àπàß√Õ∫Ê optic disc ·≈– macular ∫“ß à«π (√Ÿª∑’Ë 2.1B)
º≈ MRI ¢Õ߇∫â“μ“·≈– ¡Õß ª°μ‘ º≈μ√«®‡≈◊Õ¥ ”À√—∫ CBC, ANA, syphilis serology, antiphospholipid syndrome „Àâº≈ª°μ‘ ºŸâªÉ«¬‰¥â√—∫°“√«‘π‘®©—¬„π‡∫◊ÈÕßμâπ «à“‡ªìπ papillitis ·≈–‰¥â√—∫°“√√—°…“¥â«¬ methylpredniso- lone ©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” «—π≈– 1 °√—¡‡ªìπ‡«≈“ 3 «—π ‚¥¬ √—∫ª√–∑“π prednisolone μàÕ „π¢π“¥ 50 ¡‘≈≈‘°√—¡ μàÕ«—π
10 «—πÀ≈—ß°“√√—°…“ æ∫«à“ √–¥—∫ “¬μ“¥â“π¢«“
√Ÿª∑’Ë 2.1 A. ¿“æ∂à“¬®Õμ“¢ÕߺŸâªÉ«¬√“¬∑’Ë 2 · ¥ß„Àâ‡ÀÁπ∂÷ß ¢—È«ª√– “∑μ“¢«“∑’Ë∫«¡‚¥¬√Õ∫ B. FFA · ¥ß„Àâ‡ÀÁπ∂÷ß ’ fluorescein ∑’Ë√—Ë«ÕÕ°¡“Õ¬Ÿà√Õ∫Ê ∫√‘‡«≥ optic disc ¥â“π¢«“·≈– macula ∫“ß à«π (√Ÿª ’∑⓬‡≈à¡)
38 æ‘»‘…∞å ª√’™“«—≤πå, «‘√ߧå√Õß ÿ√—™π‘μ‘ Vol. 25 No. 1 January-June 2011
√Ÿª∑’Ë 2.3 Humphrey visual field 30-2 μ“¢«“¢ÕߺŸâªÉ«¬√“¬∑’Ë 2 ∑’Ë√–¬–‡«≈“ 10 «—π (A) 3 ‡¥◊Õπ (B) 4 ‡¥◊Õπ (C) ·≈– 6 ‡¥◊Õπ (D) · ¥ß„Àâ‡ÀÁπ∂÷ß°“√‡ª≈’ˬπ·ª≈ß∑’Ë¥’¢÷Èπμ“¡≈”¥—∫
√Ÿª∑’Ë 2.2 Humphrey visual field 30-2 ¢ÕߺŸâªÉ«¬√“¬∑’Ë 2 · ¥ß temporal visual field defect „πμ“¥â“π¢«“
39Acute Idiopathic Blind Spot Enlargement Syndrome
‡≈«≈ß ‡ªìπ 20/63 ·≈– ≈“π “¬μ“º‘¥ª°μ‘¡“°¢÷Èπ ≈—°…≥– ‡ªìπ temporal hemianopia (√Ÿª∑’Ë 2.3A) Õ¬à“߉√°Áμ“¡ °“√μ√«® FFA ´È”æ∫«à“ peripapillary leakage ≈¥≈ß°«à“ ‡¥‘¡ ºŸâªÉ«¬‰¥â√—∫°“√μ√«® pattern VEP æ∫«à“ P1 ampli- tude „πμ“¥â“π¢«“≈¥≈߇≈Á°πâÕ¬ (μË”°«à“¥â“π´â“¬ª√–¡“≥ 20%) ·μà latency ª°μ‘ full-field ERG æ∫«à“ rod ·≈– cone function Õ¬Ÿà„π‡°≥±åª°μ‘
°“√μ√«® multifocal ERG æ∫«à“¡’°“√≈¥≈ߢÕß mfERG amplitude „πμ”·Àπàß∑’Ë Õ¥§≈âÕß°—∫≈“π “¬μ“ ∑’˺‘¥ª°μ‘ (√Ÿª 2.4) ºŸâªÉ«¬‰¥â√—∫ª√–∑“π prednisoloneμàÕ ‚¥¬§àÕ¬Ê≈¥¢π“¥¬“≈ß®πÀ¬ÿ¥‰¥â„π√–¬–‡«≈“ 2 ‡¥◊Õπ æ∫ «à“ √–¥—∫ “¬μ“§àլʥ’¢÷Èπ‡ªìπ 20/20 ∑’Ë√–¬–‡«≈“ 3 ‡¥◊Õπ ·≈–≈“𠓬쓧àլʥ’¢÷Èπμ“¡≈”¥—∫ (√Ÿª∑’Ë 2.3)
√“¬ß“πºŸâªÉ«¬√“¬∑’Ë 3 ºŸâªÉ«¬™“¬‰∑¬Õ“¬ÿ 25 ªï ªØ‘‡ ∏‚√§ª√–®”μ—« ¡“μ√«®
¥â«¬Õ“°“√μ“´â“¬§àլʡ—«≈ß¡“π“π 1 —ª¥“Àå ‚¥¬‰¡à¡’ Õ“°“√º‘¥ª°μ‘Õ◊ËπÊ √–¥—∫ “¬μ“ 20/20 ∑—Èß 2 ¢â“ß pupil ¢π“¥‡∑à“°—π ‰¡àæ∫ RAPD μ√«®®Õμ“æ∫«à“¡’ optic disc edema ¥â“π´â“¬ (√Ÿª∑’Ë 3.1)
√Ÿª∑’Ë 2.4 Multifocal ERG trace array (·∂«∫π) ·≈– topographic map (·∂«≈à“ß) ¢ÕߺŸâªÉ«¬√“¬∑’Ë 2 · ¥ß„Àâ‡ÀÁπ∂÷ߧ«“¡ º‘¥ ª°μ‘¢Õß macula μ“¢«“ («ß°≈¡) „πμ”·Àπàß∑’Ë Õ¥§≈âÕß°—∫≈“𠓬μ“∑’˺‘¥ª°μ‘ (√Ÿª ’∑⓬‡≈à¡)
º≈°“√μ√«®≈“π “¬μ“ HVF 30-2 æ∫«à“¡’ blind spot enlargement „πμ“¥â“π ⓬ (√Ÿª∑’Ë 3.2A) ºŸâªÉ«¬‰¥â √—∫°“√√—°…“‚¥¬„Àâ√—∫ª√–∑“π prednisolone 60 ¡‘≈≈‘°√—¡ μàÕ«—π π“π 2 —ª¥“Àå ·≈–§àÕ¬Ê ≈¥¬“≈ß ®πÀ¬ÿ¥¬“„π √–¬–‡«≈“ 6 —ª¥“Àå º≈μ√«®μ“∑’Ë√–¬–‡«≈“ 6 —ª¥“Àå æ∫«à“ ‰¡à¡’ disc edema ·≈–≈“𠓬쓥’¢÷Èπ®π‡°◊Õ∫ª°μ‘ (√Ÿª∑’Ë 3.2B)
√Ÿª∑’Ë 3.1 ¿“æ∂à“¬®Õμ“¢ÕߺŸâªÉ«¬√“¬∑’Ë 3 · ¥ß„Àâ‡ÀÁπ∂÷ß ¢—È« ª√– “∑μ“´â“¬∑’Ë∫«¡‚¥¬√Õ∫ (√Ÿª ’∑⓬‡≈à¡)
40 æ‘»‘…∞å ª√’™“«—≤πå, «‘√ߧå√Õß ÿ√—™π‘μ‘ Vol. 25 No. 1 January-June 2011
√Ÿª∑’Ë 4 A. ¿“æ∂à“¬®Õμ“¢ÕߺŸâªÉ«¬√“¬∑’Ë 4 · ¥ß„Àâ‡ÀÁπ∂÷ߢ—È«ª√– “∑μ“´â“¬∑’Ë∫«¡‚¥¬√Õ∫ (√Ÿª ’∑⓬‡≈à¡) B. Humphrey visual field 30-2 μ“´â“¬ · ¥ß blind spot enlargement
√Ÿª∑’Ë 3.2 Humphrey visual field 30-2 μ“´â“¬ ¢ÕߺŸâªÉ«¬√“¬∑’Ë 3 · ¥ß blind spot enlargement „π«—π·√°∑’Ë¡“μ√«® (A) ·≈– °“√¥’¢÷Èπ¢Õß≈“𠓬μ“∑’Ë√–¬–‡«≈“ 6 —ª¥“ÀåÀ≈—ß°“√√—°…“ (B)
√“¬ß“πºŸâªÉ«¬√“¬∑’Ë 4 ºŸâªÉ«¬™“¬‰∑¬Õ“¬ÿ 37 ªï ªØ‘‡ ∏‚√§ª√–®”μ—« ¡“
μ√«®¥â«¬Õ“°“√μ“´â“¬¡—«¡“π“π 1 ‡¥◊Õπ √–¥—∫ “¬μ“ 20/20 ∑—Èß 2 ¢â“ß pupil ¢π“¥‡∑à“°—π ‰¡àæ∫ RAPD μ√«® ®Õμ“æ∫«à“¡’ optic disc edema ¥â“π´â“¬ (√Ÿª∑’Ë 4A)
º≈°“√μ√«®≈“π “¬μ“ HVF 30-2 æ∫«à“¡’ blind spot enlargement „πμ“¥â“π ⓬ (√Ÿª∑’Ë 4B) ºŸâªÉ«¬‰¥â√—∫ °“√√—°…“‚¥¬„Àâ√—∫ª√–∑“π prednisolone 60 ¡‘≈≈‘°√—¡ μàÕ«—π π“π 2 —ª¥“Àå ·≈–§àÕ¬Ê ≈¥¬“≈ß ®πÀ¬ÿ¥¬“„π √–¬–‡«≈“ 8 —ª¥“Àå º≈μ√«®μ“∑’Ë√–¬–‡«≈“ 8 —ª¥“Àå æ∫«à“ ‰¡à¡’ disc edema ·≈–≈“𠓬쓰≈—∫¡“‡ªìπª°μ‘
41Acute Idiopathic Blind Spot Enlargement Syndrome
∫∑«‘®“√≥å Blind spot ‡ªìπμ”·Àπàß negative scotoma ∑’Ëæ∫
‰¥â‡ªìπª°μ‘„π°“√μ√«® visual field ‡π◊ËÕß®“°‡ªìπμ”·Àπàß∑’Ë nerve fiber ¡“√«¡μ—«°—π‡ªìπ optic disc °“√¢¬“¬¢π“¥ ¢Õß blind spot “¡“√∂æ∫‰¥â„πÀ≈“¬Ê¿“«–∑’Ë∑”„À⇰‘¥ peripapillary dysfunction ‡™àπ ¿“«– high myopia ∑’Ë¡’ peripapillary atrophy ¢π“¥„À≠à·≈–¿“«–∑’Ë¡’°“√¢¬“¬ ¢π“¥¢Õß optic nerve tissue ‰ª°¥‡∫’¬¥ peripapillary retina ‡™àπ „π papilledema ·≈– optic disc anomalies (pseudodisc edema) ∫“ߪ√–‡¿∑
‚√§¢Õß®Õμ“∫“ßÕ¬à“ß æ∫«à“ “¡“√∂∑”„À⇰‘¥§«“¡ º‘¥ª°μ‘‡©æ“–∑’Ë∫√‘‡«≥ peripapillary retina ‡ªìπÀ≈—° ·≈– ∑”„À⺟âªÉ«¬¡“¥â«¬Õ“°“√μ“¡—«®“°°“√∑’Ë¡’°“√¢¬“¬μ—«¢Õß blind spot ‰¥â μ—«Õ¬à“ߢÕß‚√§¥—ß°≈à“«‰¥â·°à AIBSE, AZOOR ·≈– MEWDS
√“¬ß“π©∫—∫π’È𔇠πÕºŸâªÉ«¬ 4 √“¬ ∑’ˉ¥â√—∫°“√ «‘π‘®©—¬«à“‡ªìπ acute idiopathic blind spot enlargement syndrome ºŸâªÉ«¬∑ÿ°√“¬¡’≈—°…≥–∑“ߧ≈‘π‘°À≈“¬Õ¬à“ß∑’Ë §≈⓬§≈÷ß°—π §◊Õ Õ“¬ÿÕ¬Ÿà„π™à«ß young adult (18-37 ªï) ¡“æ∫®—°…ÿ·æ∑¬å¥â«¬Õ“°“√ painless unilateral temporal scotoma ‚¥¬∑’Ë visual function Õ¬Ÿà„π‡°≥±åª°μ‘ (visual acuity 20/20 3 √“¬ ·≈– 20/25 1 √“¬ ∑ÿ°√“¬μ√«® color vision „Àâº≈ª°μ‘) ¬°‡«âπ°“√μ√«®≈“𠓬μ“∑’Ë®– æ∫«à“¡’ blind spot enlargement °“√μ√«®®–‰¡à§«“¡ º‘¥ª°μ‘¢Õßμ“ à«πÕ◊ËπÊ ¬°‡«âπ disc edema (3 „π 4 √“¬) ‚¥¬≈—°…≥– disc ®–∫«¡∑—Ë«Ê ‚¥¬√Õ∫ ·≈–‰¡àæ∫«à“¡’ peri- papillary hemorrhage, venous dilatation À√◊Õ cotton wool spot ºŸâªÉ«¬∑ÿ°√“¬„π√“¬ß“ππ’È μ√«®‰¡àæ∫√àÕß√Õ¬ ¢Õß chorioretinitis ∑’Ë®Õμ“ à«πÕ◊ËπÊ Õ“°“√ photopsia æ∫„πºŸâªÉ«¬‡æ’¬ß 1 √“¬ ·≈–‰¡àæ∫«à“¡’ª√–«—μ‘Õ“°“√¢Õß viral illness π”¡“°àÕπ
ºŸâªÉ«¬√“¬∑’Ë 3 ·≈– 4 °“√«‘π‘®©—¬¿“«–π’È “¡“√∂∑” ‰¥âßà“¬‚¥¬‰¡àμâÕßÕ“»—¬°“√μ√«®æ‘‡»…‡æ‘Ë¡‡μ‘¡Õ◊ËπÊ ·μà„π ºŸâªÉ«¬√“¬∑’Ë 1 ·≈– 2 ¢π“¥¢Õß blind spot ¡’¢π“¥„À≠à ¡“°®π‡°◊Õ∫‡μÁ¡ temporal part ¢Õß central visual field ®÷ß∑”„Àâμ√«®æ∫ RAPD ‰¥â ÷ËßÕ“®π”‰ª Ÿà°“√«‘π‘®©—¬ optic neuritis À√◊Õ§‘¥∂÷ß√Õ¬‚√§∫√‘‡«≥ optic chiasm ®π𔉪 Ÿà °“√ àßμ√«® neuroimaging ÷Ëß¡’§à“„™â®à“¬§àÕπ¢â“ß Ÿß °“√ àßμ√«® multifocal ERG „πºŸâªÉ«¬∑’Ë ß —¬¿“«–π’È®–™à«¬
¬◊π¬—π«à“ temporal scotoma∑’ˇ°‘¥¢÷È𠇪ìπ®“°°“√∑”ß“π ∑’˺‘¥ª°μ‘¢Õß outer retina ¥—ß· ¥ß„π√Ÿª 1.2 ·≈– 2.4 ·≈–Õ“®™à«¬≈¥°“√ àßμ√«®Õ◊ËπÊ∑’ˉ¡à®”‡ªìπ‰¥â
∑—Èß AIBSE ·≈– MEWDS ¡’≈—°…≥–∑“ߧ≈‘π‘°∫“ß Õ¬à“ß∑’ˇÀ¡◊Õπ°—π‰¥â ‚¥¬∑—Èß 2 ‚√§¡—°®–¡“¥â«¬Õ“°“√¢Õß acute visual deficit √à«¡°—∫¡’ photopsia ·≈–æ∫‰¥â∫àÕ¬ „π young myopic female ·μຟâªÉ«¬ MEWDS ®–μ√«® æ∫«à“¡’ white spot ∑’ËÕ¬Ÿà„π√–¥—∫¢Õß outer retina √à«¡ °—∫Õ“®æ∫«à“¡’ vitreous cell, retinal vascular sheathing À√◊Õ optic disc edema √à«¡¥â«¬‰¥â7 „π¢≥–∑’˺ŸâªÉ«¬ AIBSE ®–¡’ blind spot enlargement (√à«¡°—∫ disc edema „π ∫“ß√“¬) ‡ªìπ isolated finding °“√μ√«® FFA ‡æ◊ËÕ¡Õß À“√Õ¬‚√§¢Õß choroid À√◊Õ retina Õ“®™à«¬„π°“√«‘π‘®©—¬ ·¬°‚√§‰¥â¡“°¢÷Èπ
°“√«‘π‘®©—¬ AZOOR ª√–°Õ∫¥â«¬ Õ“°“√¢Õß pho- topsia √à«¡°—∫ acute visual field defect ´÷Ë߇°‘¥®“° §«“¡º‘¥ª°μ‘¢Õß outer retina ‚¥¬∑’Ë°“√μ√«®®Õμ“®– ª°μ‘„π™à«ß·√° ·≈–æ∫«à“¡’ RPE atrophy „πμ”·ÀπàߢÕß ®Õμ“∑’Ë Õ¥§≈âÕß°—∫≈“𠓬μ“∑’˺‘¥ª°μ‘‡¡◊ËÕ‡«≈“ºà“π‰ª5
∂÷ß·¡â«à“ºŸâªÉ«¬∑ÿ°√“¬„π√“¬ß“π©∫—∫π’È®–æ∫«à“Õ“°“√ ¥’¢÷ÈπÀ≈—߉¥â°“√√—°…“¥â«¬ systemic steroid ·μàªí®®ÿ∫—π¬—ß ‰¡à¡’À≈—°∞“π∑’ˇ™◊ËÕ∂◊Õ‰¥â«à“°“√„Àâ ‡μ’¬√Õ¬¥å®–‰¥âª√–‚¬™πå ®√‘ß„πºŸâªÉ«¬ AIBSE ‚¥¬‡¡◊ËÕ¥Ÿ®“°√“¬ß“πºŸâªÉ«¬∑’˺à“π¡“ æ∫«à“ ‚√§π’È “¡“√∂¥’¢÷Èπ‡Õ߉¥â‚¥¬‰¡àμâÕß„Àâ°“√√—°…“„¥Ê1-3
√«¡∂÷ß®“°ª√–«—μ‘„πºŸâªÉ«¬√“¬∑’Ë 2 ®–‡ÀÁπ‰¥â«à“√–¥—∫ “¬μ“ ·≈–≈“π “¬μ“ ‡≈«≈ßÀ≈—ß®“°‰¥â√—∫°“√√—°…“¥â«¬ ‡μ’¬√Õ¬¥å „π√–¬–·√°
‡Õ° “√Õâ“ßÕ‘ß 1. Miller NR. The big blind spot syndrome: unilateral optic disc
edema without visual loss or increased intracranial pressure. In: Smith JL, editor. Neuro-ophthalmology Update. New York: Masson Pub, 1977:163-9.
2. Rosenberg ML, OûConnor P, Carter J. Idiopathic unilateral disc edema. J ClinNeuroophthalmol 1984;4:181-4.
3. Fletcher WA, Imes RK, Goodman D, Hoyt WF. Acute idiopathic blind spot enlargement. A big blind spot syndrome without optic disc edema. Arch Ophthalmol 1988;106:44-9.
4. Volpe NJ, Rizzo JF III, Lessell S. Acute idiopathic blind spot enlargement syndrome. A review of 27 new cases. Arch Ophthalmol 2001;119:59-63.
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5. Watzke RC, Shults WT. Clinical features and natural history of the acute idiopathic enlarged blind spot syndrome. Ophthalmology 2002;109:1326-35.
6. Callanan D, Gass JD. Multifocal choroiditis and choroidal neovascularization associated with the multiple evanescent
white dot and acute idiopathic blind spot enlargement syndrome. Ophthalmology 1992;99:1678-85.
Acute Idiopathic Blind Spot Enlargement Syndrome
Pisit Preechawat, M.D Virongrong Surushniti, M.D.
Abstract Unilateral blind spot enlargement can occur as an isolated entity (acute idiopathic blind spot enlarge-
ment) or in association with various chorioretinal diseases. The authors report four cases of acute idiopathic blind spot enlargement who presented with unilateral temporal scotoma. All cases had normal visual acuity and color vision. Optic disc edema was presented in 3 patients. There was no other ocular abnormality in all patients.Recovery of visual field occurred in all cases after treatment with a short course of systemic steroid. Thai J Ophthalmol 2011; January-June 25(1): 33-42.
Case Report/√“¬ß“πºŸâªÉ«¬
Acute Idiopathic Blind Spot Enlargement Syndrome
Case Report/√“¬ß“πºŸâªÉ«¬
¿“§«‘™“®—°…ÿ«‘∑¬“ §≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
∫∑§—¥¬àÕ ¿“«–∑’Ë¡’°“√¢¬“¬¢π“¥¢Õß blind spot “¡“√∂‡°‘¥¢÷Èπ‰¥â‚¥¬‰¡à∑√“∫ “‡Àμÿ ‡√’¬°«à“acute idiopathic blind spot
enlargement À√◊Õæ∫√à«¡°—∫‚√§¢ÕߧÕ√Õ¬¥åÀ√◊Õ®Õμ“∫“ߪ√–‡¿∑ √“¬ß“πºŸâªÉ«¬ 4 √“¬∑’Ë¡“¥â«¬Õ“°“√¡Õ߉¡à™—¥„π∫√‘‡«≥
temporal ¢Õßμ“¥â“π„¥¥â“πÀπ÷Ëß ·≈–‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ acute idiopathic blind spot enlargement æ∫«à“ºŸâªÉ«¬
∑ÿ°√“¬¡’√–¥—∫ “¬μ“·≈–°“√¡Õ߇ÀÁπ ’ª°μ‘ μ√«®æ∫«à“¡’°“√∫«¡¢Õߢ—È«ª√– “∑μ“„πºŸâªÉ«¬ 3 √“¬ ‚¥¬‰¡àæ∫«à“¡’§«“¡
º‘¥ª°μ‘¢Õßμ“ à«πÕ◊Ëπ√à«¡¥â«¬ ¿“¬À≈—ß°“√√—°…“¥â«¬¬“ ‡μ’¬√Õ¬¥å„π√–¬– —Èπ æ∫«à“≈“π “¬μ“¢ÕߺŸâªÉ«¬∑ÿ°√“¬ “¡“√∂
øóôπμ—«°≈—∫¡“‡ªìπª°μ‘‰¥â ®—°…ÿ‡«™ “√ 2554; ¡°√“§¡-¡‘∂ÿπ“¬π 25(1): 33-42.
«‘√ߧå√Õß ÿ√—™π‘μ‘, æ.∫.
æ‘»‘…∞å ª√’™“«—≤πå, æ.∫.
35Acute Idiopathic Blind Spot Enlargement Syndrome
∫∑π” Blind spot enlargement syndrome ‡ªìπ°≈ÿà¡
‚√§∑’Ë¡’§«“¡º‘¥ª°μ‘¢Õß peripapillary retina ´÷Ëßæ∫‰¥â ‰¡à ∫àÕ¬ ·≈–¬—߉¡à∑√“∫°≈‰°„π°“√‡°‘¥‚√§∑’Ë™—¥‡®π ‡π◊ËÕß®“° °“√«‘π‘®©—¬¿“«–π’È ¬—߉¡à¡’ criteria ·≈– classification ∑’Ë ·πàπÕπ ¥—ßπ—Èπ®“°√“¬ß“π∑’˺à“π¡“®÷ßæ∫«à“¡’§«“¡À≈“° À≈“¬¢ÕߺŸâªÉ«¬∑’ˉ¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ‚√§π’È Õ¬Ÿà¡“°1-7
Miller1 ·≈– Rosenberg2 √“¬ß“πºŸâªÉ«¬ „πªï §.». 1977 ·≈– 1984 ∑—ÈßÀ¡¥ 10 √“¬ ∑’Ëμ√«®æ∫«à“¡’ unilateral disc edema ‚¥¬‰¡àæ∫«à“¡’ increased intracranial pressure √à«¡¥â«¬ ·≈–‰¡à¡’ optic nerve dysfunction ¬°‡«âπ blind spot enlargement ®“°°“√μ√«®≈“π “¬μ“ ¿“«–π’È∂Ÿ°‡√’¬°«à“ çthe big blind spot syndromeé
„πªï §.». 1988 Fletcher3 √“¬ß“πºŸâªÉ«¬ 5 √“¬∑’Ë¡“ ¥â«¬ unilateral blind spot enlargement with normal visual acuity ·μàμà“ß°—∫√“¬ß“π°àÕπÀπâ“π’Èμ√ß∑’Ë«à“ºŸâªÉ«¬ ∑ÿ°√“¬‰¡à¡’ optic disc edema √à«¡¥â«¬ ¿“«–π’È∂Ÿ°‡√’¬°«à“ acute idiopathic blind spot enlargement (AIBSE) syndrome
®“°À≈—°∞“π∑’Ë¡’„π‡«≈“μàÕ¡“ ‡™◊ËÕ«à“ AIBSE·≈– big blind spot syndrome ‡ªìπ‚√§‡¥’¬«°—π ·≈–Õ“®‡ªìπ
√Ÿª∑’Ë 1.1 Humphrey visual field 30-2 ¢ÕߺŸâªÉ«¬√“¬∑’Ë 1 · ¥ß temporal visual field defect „πμ“¥â“π¢«“
spectrum Àπ÷Ëß ¢Õß‚√§„π°≈ÿࡇ¥’¬«°—∫chorioretinitis∫“ß Õ¬à“ß ‡™àπ multiple evanescent white dot syndrome (MEWDS), acute zonal occult outer retinopathy (AZOOR), multifocal choroiditis·≈– acute macular neuroretinopathy
√“¬ß“π©∫—∫π’È¢Õ𔇠πÕºŸâªÉ«¬ 4 √“¬∑’Ë¡“¥â«¬Õ“°“√ ¢Õß unilateral temporal scotoma ·≈–¡’≈—°…≥–∑“ß §≈‘π‘°∑’ˇ¢â“‰¥â°—∫¿“«– AIBSE
√“¬ß“πºŸâªÉ«¬√“¬∑’Ë 1 ºŸâªÉ«¬À≠‘߉∑¬Õ“¬ÿ 18 ªï ¡“μ√«®¥â«¬Õ“°“√μ“¢«“
¡—«¡Õ߇ÀÁπ¿“æ∫“ß à«π¢“¥À“¬‰ª ¡“π“π 3 «—π ‰¡à¡’ Õ“°“√ª«¥»’√…–À√◊Õª«¥μ“ ‰¡à¡’‰¢â·≈–Õ“°“√º‘¥ª°μ‘Õ◊ËπÊ
√–¥—∫ “¬μ“ 20/20 ∑—Èß 2 ¢â“ß anterior segment ª°μ‘ pupil ¢π“¥ 3 ¡¡ ‡∑à“°—π∑—Èß 2 ¥â“π μ√«®æ∫ rela- tive afferent pupillary defect (RAPD) ¢π“¥ 0.3 log unit „πμ“¥â“π¢«“ º≈°“√μ√«®®Õ쓪°μ‘·≈–°“√¡Õ߇ÀÁπ ’ (color vision) ª°μ‘∑—Èß 2 ¢â“ß
º≈°“√μ√«®≈“π “¬μ“ Humphrey visual field (HVF) 30-2 æ∫«à“¡’ right temporal visual field defect (√Ÿª∑’Ë 1.1) Magnetic resonance imaging (MRI) ¢Õß
36 æ‘»‘…∞å ª√’™“«—≤πå, «‘√ߧå√Õß ÿ√—™π‘μ‘ Vol. 25 No. 1 January-June 2011
√Ÿª∑’Ë 1.2 Multifocal ERG trace array (·∂«∫π) ·≈– topographic map (·∂«≈à“ß) ¢ÕߺŸâªÉ«¬√“¬∑’Ë 1 · ¥ß„Àâ‡ÀÁπ∂÷ߧ«“¡ º‘¥ª°μ‘¢Õß macula μ“¢«“ («ß°≈¡) „πμ”·Àπàß∑’Ë Õ¥§≈âÕß°—∫≈“𠓬μ“∑’˺‘¥ª°μ‘ (¥Ÿ‡ª√’¬∫‡∑’¬∫°—∫μ“´â“¬∑’˪°μ‘) (√Ÿª ’∑⓬‡≈à¡)
√Ÿª∑’Ë 1.3 Humphrey visual field 30-2 μ“¢«“¢ÕߺŸâªÉ«¬√“¬∑’Ë 1 ∑’Ë√–¬–‡«≈“ 10 «—π (A) 3 —ª¥“Àå (B) 7 —ª¥“Àå (C) ·≈– 4 ‡¥◊Õπ (D) · ¥ß„Àâ‡ÀÁπ∂÷ß°“√‡ª≈’ˬπ·ª≈ß∑’Ë¥’¢÷Èπμ“¡≈”¥—∫
‡∫â“μ“·≈– ¡Õß ‰¡àæ∫«à“¡’§«“¡º‘¥ª°μ‘¢Õß optic nerve signal ·≈–‰¡àæ∫√Õ¬‚√§„π ¡Õß Õ¬à“߉√°Áμ“¡ºŸâªÉ«¬‰¥â √—∫°“√«‘π‘®©—¬„π‡∫◊ÈÕßμâπ«à“‡ªìπ right retrobulbar optic neuropathy ‚¥¬§‘¥∂÷ß “‡Àμÿ„π°≈ÿà¡ optic neuritis ¡“° ∑’Ë ÿ¥ º≈°“√μ√«®‡≈◊Õ¥ complete blood count (CBC)
erythrocyte sedimentation rate (ESR) ·≈– anti-nuclear antibody (ANA) ª°μ‘
ºŸâªÉ«¬‰¥â√—∫°“√√—°…“¥â«¬ methylprednisolone ©’¥ ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” «—π≈– 1 °√—¡‡ªìπ‡«≈“ 3 «—π·≈– √—∫ª√–∑“π prednisolone μàÕ „π¢π“¥ 60 ¡‘≈≈‘°√—¡μàÕ«—π
37Acute Idiopathic Blind Spot Enlargement Syndrome
Õß —ª¥“ÀåÀ≈—ß°“√√—°…“ ºŸâªÉ«¬‰¥â√—∫°“√μ√«® pattern visual evoked potential (VEP) º≈°“√μ√«®æ∫ «à“ P1 amplitude ·≈– latency ª°μ‘∑—Èß 2 ¢â“ß º≈°“√ μ√«® multifocal electroretinogram (mfERG) æ∫«à“¡’ °“√≈¥≈ߢÕß mfERG amplitude „πμ”·Àπàß∑’Ë Õ¥§≈âÕß °—∫≈“𠓬μ“∑’˺‘¥ª°μ‘ (√Ÿª∑’Ë 1.2) ´÷Ëß®“°º≈°“√μ√«®¥—ß °≈à“« · ¥ß„Àâ‡ÀÁπ«à“ “‡Àμÿ¢Õß temporal visual field defect„πºŸâªÉ«¬√“¬π’È ‰¡à‰¥â‡°‘¥®“° ganglion cell À√◊Õ nerve fiber defect ·μà‡°‘¥®“°§«“¡º‘¥ª°μ‘¢Õß outer retina ºŸâªÉ«¬‰¥â√—∫°“√«‘π‘®©—¬„π∑⓬∑’Ë ÿ¥«à“‡ªìπ AIBSE ·≈–§àÕ¬Ê ≈¥¢π“¥¬“ prednisolone ≈ß®πÀ¬ÿ¥‰¥â„π√–¬–‡«≈“ 6 —ª¥“Àå
μ√«®≈“𠓬μ“æ∫≈—°…≥– temporal visual filed defect ¡’¢π“¥‡≈Á°≈ß·≈–À¥·§∫≈߇√◊Ëլʇ¢â“À“μ”·Àπàß ¢Õß blind spot
√“¬ß“πºŸâªÉ«¬√“¬∑’Ë 2 ºŸâªÉ«¬À≠‘߉∑¬Õ“¬ÿ 34 ªï ªØ‘‡ ∏‚√§ª√–®”μ—«¡“
μ√«®¥â«¬Õ“°“√μ“¢«“§àլʡ—«≈ß¡“π“π 1 ‡¥◊Õπ ∫“ß §√—È߇ÀÁπ· ß«“∫∫√‘‡«≥À“ßμ“ ·μà‰¡à¡’Õ“°“√º‘¥ª°μ‘Õ◊ËπÊ
√–¥—∫ “¬μ“ 20/25 „πμ“¢«“ ·≈– 20/20 „πμ“ ´â“¬ºŸâªÉ«¬¡’ “¬μ“ —Èπ -6.00 diopters ∑—Èß Õߢâ“ß anterior segment ª°μ‘ pupil ¢π“¥ 3 ¡¡. ‡∑à“°—π∑—Èß 2 ¥â“π μ√«® æ∫ RAPD „πμ“¥â“π¢«“ º≈°“√μ√«®®Õμ“æ∫«à“¡’ disc edema „πμ“¥â“π¢«“ (√Ÿª∑’Ë 2.1A) °“√¡Õ߇ÀÁπ ’ ª°μ‘∑—Èß 2 ¢â“ß
º≈°“√μ√«®≈“π “¬μ“ HVF 30-2 æ∫«à“¡’ right temporal visual field defect (√Ÿª∑’Ë 2.2) ‚¥¬≈—°…≥– ≈“𠓬μ“∑’˺‘¥ª°μ‘¡’®ÿ¥»Ÿπ¬å°≈“ß∑’Ëμ”·Àπàß blind spot º≈°“√μ√«® fundus fluorescein angiogram (FFA) æ∫ «à“¡’ fluorescein leakage ∑’Ëμ”·Àπàß√Õ∫Ê optic disc ·≈– macular ∫“ß à«π (√Ÿª∑’Ë 2.1B)
º≈ MRI ¢Õ߇∫â“μ“·≈– ¡Õß ª°μ‘ º≈μ√«®‡≈◊Õ¥ ”À√—∫ CBC, ANA, syphilis serology, antiphospholipid syndrome „Àâº≈ª°μ‘ ºŸâªÉ«¬‰¥â√—∫°“√«‘π‘®©—¬„π‡∫◊ÈÕßμâπ «à“‡ªìπ papillitis ·≈–‰¥â√—∫°“√√—°…“¥â«¬ methylpredniso- lone ©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” «—π≈– 1 °√—¡‡ªìπ‡«≈“ 3 «—π ‚¥¬ √—∫ª√–∑“π prednisolone μàÕ „π¢π“¥ 50 ¡‘≈≈‘°√—¡ μàÕ«—π
10 «—πÀ≈—ß°“√√—°…“ æ∫«à“ √–¥—∫ “¬μ“¥â“π¢«“
√Ÿª∑’Ë 2.1 A. ¿“æ∂à“¬®Õμ“¢ÕߺŸâªÉ«¬√“¬∑’Ë 2 · ¥ß„Àâ‡ÀÁπ∂÷ß ¢—È«ª√– “∑μ“¢«“∑’Ë∫«¡‚¥¬√Õ∫ B. FFA · ¥ß„Àâ‡ÀÁπ∂÷ß ’ fluorescein ∑’Ë√—Ë«ÕÕ°¡“Õ¬Ÿà√Õ∫Ê ∫√‘‡«≥ optic disc ¥â“π¢«“·≈– macula ∫“ß à«π (√Ÿª ’∑⓬‡≈à¡)
38 æ‘»‘…∞å ª√’™“«—≤πå, «‘√ߧå√Õß ÿ√—™π‘μ‘ Vol. 25 No. 1 January-June 2011
√Ÿª∑’Ë 2.3 Humphrey visual field 30-2 μ“¢«“¢ÕߺŸâªÉ«¬√“¬∑’Ë 2 ∑’Ë√–¬–‡«≈“ 10 «—π (A) 3 ‡¥◊Õπ (B) 4 ‡¥◊Õπ (C) ·≈– 6 ‡¥◊Õπ (D) · ¥ß„Àâ‡ÀÁπ∂÷ß°“√‡ª≈’ˬπ·ª≈ß∑’Ë¥’¢÷Èπμ“¡≈”¥—∫
√Ÿª∑’Ë 2.2 Humphrey visual field 30-2 ¢ÕߺŸâªÉ«¬√“¬∑’Ë 2 · ¥ß temporal visual field defect „πμ“¥â“π¢«“
39Acute Idiopathic Blind Spot Enlargement Syndrome
‡≈«≈ß ‡ªìπ 20/63 ·≈– ≈“π “¬μ“º‘¥ª°μ‘¡“°¢÷Èπ ≈—°…≥– ‡ªìπ temporal hemianopia (√Ÿª∑’Ë 2.3A) Õ¬à“߉√°Áμ“¡ °“√μ√«® FFA ´È”æ∫«à“ peripapillary leakage ≈¥≈ß°«à“ ‡¥‘¡ ºŸâªÉ«¬‰¥â√—∫°“√μ√«® pattern VEP æ∫«à“ P1 ampli- tude „πμ“¥â“π¢«“≈¥≈߇≈Á°πâÕ¬ (μË”°«à“¥â“π´â“¬ª√–¡“≥ 20%) ·μà latency ª°μ‘ full-field ERG æ∫«à“ rod ·≈– cone function Õ¬Ÿà„π‡°≥±åª°μ‘
°“√μ√«® multifocal ERG æ∫«à“¡’°“√≈¥≈ߢÕß mfERG amplitude „πμ”·Àπàß∑’Ë Õ¥§≈âÕß°—∫≈“π “¬μ“ ∑’˺‘¥ª°μ‘ (√Ÿª 2.4) ºŸâªÉ«¬‰¥â√—∫ª√–∑“π prednisoloneμàÕ ‚¥¬§àÕ¬Ê≈¥¢π“¥¬“≈ß®πÀ¬ÿ¥‰¥â„π√–¬–‡«≈“ 2 ‡¥◊Õπ æ∫ «à“ √–¥—∫ “¬μ“§àլʥ’¢÷Èπ‡ªìπ 20/20 ∑’Ë√–¬–‡«≈“ 3 ‡¥◊Õπ ·≈–≈“𠓬쓧àլʥ’¢÷Èπμ“¡≈”¥—∫ (√Ÿª∑’Ë 2.3)
√“¬ß“πºŸâªÉ«¬√“¬∑’Ë 3 ºŸâªÉ«¬™“¬‰∑¬Õ“¬ÿ 25 ªï ªØ‘‡ ∏‚√§ª√–®”μ—« ¡“μ√«®
¥â«¬Õ“°“√μ“´â“¬§àլʡ—«≈ß¡“π“π 1 —ª¥“Àå ‚¥¬‰¡à¡’ Õ“°“√º‘¥ª°μ‘Õ◊ËπÊ √–¥—∫ “¬μ“ 20/20 ∑—Èß 2 ¢â“ß pupil ¢π“¥‡∑à“°—π ‰¡àæ∫ RAPD μ√«®®Õμ“æ∫«à“¡’ optic disc edema ¥â“π´â“¬ (√Ÿª∑’Ë 3.1)
√Ÿª∑’Ë 2.4 Multifocal ERG trace array (·∂«∫π) ·≈– topographic map (·∂«≈à“ß) ¢ÕߺŸâªÉ«¬√“¬∑’Ë 2 · ¥ß„Àâ‡ÀÁπ∂÷ߧ«“¡ º‘¥ ª°μ‘¢Õß macula μ“¢«“ («ß°≈¡) „πμ”·Àπàß∑’Ë Õ¥§≈âÕß°—∫≈“𠓬μ“∑’˺‘¥ª°μ‘ (√Ÿª ’∑⓬‡≈à¡)
º≈°“√μ√«®≈“π “¬μ“ HVF 30-2 æ∫«à“¡’ blind spot enlargement „πμ“¥â“π ⓬ (√Ÿª∑’Ë 3.2A) ºŸâªÉ«¬‰¥â √—∫°“√√—°…“‚¥¬„Àâ√—∫ª√–∑“π prednisolone 60 ¡‘≈≈‘°√—¡ μàÕ«—π π“π 2 —ª¥“Àå ·≈–§àÕ¬Ê ≈¥¬“≈ß ®πÀ¬ÿ¥¬“„π √–¬–‡«≈“ 6 —ª¥“Àå º≈μ√«®μ“∑’Ë√–¬–‡«≈“ 6 —ª¥“Àå æ∫«à“ ‰¡à¡’ disc edema ·≈–≈“𠓬쓥’¢÷Èπ®π‡°◊Õ∫ª°μ‘ (√Ÿª∑’Ë 3.2B)
√Ÿª∑’Ë 3.1 ¿“æ∂à“¬®Õμ“¢ÕߺŸâªÉ«¬√“¬∑’Ë 3 · ¥ß„Àâ‡ÀÁπ∂÷ß ¢—È« ª√– “∑μ“´â“¬∑’Ë∫«¡‚¥¬√Õ∫ (√Ÿª ’∑⓬‡≈à¡)
40 æ‘»‘…∞å ª√’™“«—≤πå, «‘√ߧå√Õß ÿ√—™π‘μ‘ Vol. 25 No. 1 January-June 2011
√Ÿª∑’Ë 4 A. ¿“æ∂à“¬®Õμ“¢ÕߺŸâªÉ«¬√“¬∑’Ë 4 · ¥ß„Àâ‡ÀÁπ∂÷ߢ—È«ª√– “∑μ“´â“¬∑’Ë∫«¡‚¥¬√Õ∫ (√Ÿª ’∑⓬‡≈à¡) B. Humphrey visual field 30-2 μ“´â“¬ · ¥ß blind spot enlargement
√Ÿª∑’Ë 3.2 Humphrey visual field 30-2 μ“´â“¬ ¢ÕߺŸâªÉ«¬√“¬∑’Ë 3 · ¥ß blind spot enlargement „π«—π·√°∑’Ë¡“μ√«® (A) ·≈– °“√¥’¢÷Èπ¢Õß≈“𠓬μ“∑’Ë√–¬–‡«≈“ 6 —ª¥“ÀåÀ≈—ß°“√√—°…“ (B)
√“¬ß“πºŸâªÉ«¬√“¬∑’Ë 4 ºŸâªÉ«¬™“¬‰∑¬Õ“¬ÿ 37 ªï ªØ‘‡ ∏‚√§ª√–®”μ—« ¡“
μ√«®¥â«¬Õ“°“√μ“´â“¬¡—«¡“π“π 1 ‡¥◊Õπ √–¥—∫ “¬μ“ 20/20 ∑—Èß 2 ¢â“ß pupil ¢π“¥‡∑à“°—π ‰¡àæ∫ RAPD μ√«® ®Õμ“æ∫«à“¡’ optic disc edema ¥â“π´â“¬ (√Ÿª∑’Ë 4A)
º≈°“√μ√«®≈“π “¬μ“ HVF 30-2 æ∫«à“¡’ blind spot enlargement „πμ“¥â“π ⓬ (√Ÿª∑’Ë 4B) ºŸâªÉ«¬‰¥â√—∫ °“√√—°…“‚¥¬„Àâ√—∫ª√–∑“π prednisolone 60 ¡‘≈≈‘°√—¡ μàÕ«—π π“π 2 —ª¥“Àå ·≈–§àÕ¬Ê ≈¥¬“≈ß ®πÀ¬ÿ¥¬“„π √–¬–‡«≈“ 8 —ª¥“Àå º≈μ√«®μ“∑’Ë√–¬–‡«≈“ 8 —ª¥“Àå æ∫«à“ ‰¡à¡’ disc edema ·≈–≈“𠓬쓰≈—∫¡“‡ªìπª°μ‘
41Acute Idiopathic Blind Spot Enlargement Syndrome
∫∑«‘®“√≥å Blind spot ‡ªìπμ”·Àπàß negative scotoma ∑’Ëæ∫
‰¥â‡ªìπª°μ‘„π°“√μ√«® visual field ‡π◊ËÕß®“°‡ªìπμ”·Àπàß∑’Ë nerve fiber ¡“√«¡μ—«°—π‡ªìπ optic disc °“√¢¬“¬¢π“¥ ¢Õß blind spot “¡“√∂æ∫‰¥â„πÀ≈“¬Ê¿“«–∑’Ë∑”„À⇰‘¥ peripapillary dysfunction ‡™àπ ¿“«– high myopia ∑’Ë¡’ peripapillary atrophy ¢π“¥„À≠à·≈–¿“«–∑’Ë¡’°“√¢¬“¬ ¢π“¥¢Õß optic nerve tissue ‰ª°¥‡∫’¬¥ peripapillary retina ‡™àπ „π papilledema ·≈– optic disc anomalies (pseudodisc edema) ∫“ߪ√–‡¿∑
‚√§¢Õß®Õμ“∫“ßÕ¬à“ß æ∫«à“ “¡“√∂∑”„À⇰‘¥§«“¡ º‘¥ª°μ‘‡©æ“–∑’Ë∫√‘‡«≥ peripapillary retina ‡ªìπÀ≈—° ·≈– ∑”„À⺟âªÉ«¬¡“¥â«¬Õ“°“√μ“¡—«®“°°“√∑’Ë¡’°“√¢¬“¬μ—«¢Õß blind spot ‰¥â μ—«Õ¬à“ߢÕß‚√§¥—ß°≈à“«‰¥â·°à AIBSE, AZOOR ·≈– MEWDS
√“¬ß“π©∫—∫π’È𔇠πÕºŸâªÉ«¬ 4 √“¬ ∑’ˉ¥â√—∫°“√ «‘π‘®©—¬«à“‡ªìπ acute idiopathic blind spot enlargement syndrome ºŸâªÉ«¬∑ÿ°√“¬¡’≈—°…≥–∑“ߧ≈‘π‘°À≈“¬Õ¬à“ß∑’Ë §≈⓬§≈÷ß°—π §◊Õ Õ“¬ÿÕ¬Ÿà„π™à«ß young adult (18-37 ªï) ¡“æ∫®—°…ÿ·æ∑¬å¥â«¬Õ“°“√ painless unilateral temporal scotoma ‚¥¬∑’Ë visual function Õ¬Ÿà„π‡°≥±åª°μ‘ (visual acuity 20/20 3 √“¬ ·≈– 20/25 1 √“¬ ∑ÿ°√“¬μ√«® color vision „Àâº≈ª°μ‘) ¬°‡«âπ°“√μ√«®≈“𠓬μ“∑’Ë®– æ∫«à“¡’ blind spot enlargement °“√μ√«®®–‰¡à§«“¡ º‘¥ª°μ‘¢Õßμ“ à«πÕ◊ËπÊ ¬°‡«âπ disc edema (3 „π 4 √“¬) ‚¥¬≈—°…≥– disc ®–∫«¡∑—Ë«Ê ‚¥¬√Õ∫ ·≈–‰¡àæ∫«à“¡’ peri- papillary hemorrhage, venous dilatation À√◊Õ cotton wool spot ºŸâªÉ«¬∑ÿ°√“¬„π√“¬ß“ππ’È μ√«®‰¡àæ∫√àÕß√Õ¬ ¢Õß chorioretinitis ∑’Ë®Õμ“ à«πÕ◊ËπÊ Õ“°“√ photopsia æ∫„πºŸâªÉ«¬‡æ’¬ß 1 √“¬ ·≈–‰¡àæ∫«à“¡’ª√–«—μ‘Õ“°“√¢Õß viral illness π”¡“°àÕπ
ºŸâªÉ«¬√“¬∑’Ë 3 ·≈– 4 °“√«‘π‘®©—¬¿“«–π’È “¡“√∂∑” ‰¥âßà“¬‚¥¬‰¡àμâÕßÕ“»—¬°“√μ√«®æ‘‡»…‡æ‘Ë¡‡μ‘¡Õ◊ËπÊ ·μà„π ºŸâªÉ«¬√“¬∑’Ë 1 ·≈– 2 ¢π“¥¢Õß blind spot ¡’¢π“¥„À≠à ¡“°®π‡°◊Õ∫‡μÁ¡ temporal part ¢Õß central visual field ®÷ß∑”„Àâμ√«®æ∫ RAPD ‰¥â ÷ËßÕ“®π”‰ª Ÿà°“√«‘π‘®©—¬ optic neuritis À√◊Õ§‘¥∂÷ß√Õ¬‚√§∫√‘‡«≥ optic chiasm ®π𔉪 Ÿà °“√ àßμ√«® neuroimaging ÷Ëß¡’§à“„™â®à“¬§àÕπ¢â“ß Ÿß °“√ àßμ√«® multifocal ERG „πºŸâªÉ«¬∑’Ë ß —¬¿“«–π’È®–™à«¬
¬◊π¬—π«à“ temporal scotoma∑’ˇ°‘¥¢÷È𠇪ìπ®“°°“√∑”ß“π ∑’˺‘¥ª°μ‘¢Õß outer retina ¥—ß· ¥ß„π√Ÿª 1.2 ·≈– 2.4 ·≈–Õ“®™à«¬≈¥°“√ àßμ√«®Õ◊ËπÊ∑’ˉ¡à®”‡ªìπ‰¥â
∑—Èß AIBSE ·≈– MEWDS ¡’≈—°…≥–∑“ߧ≈‘π‘°∫“ß Õ¬à“ß∑’ˇÀ¡◊Õπ°—π‰¥â ‚¥¬∑—Èß 2 ‚√§¡—°®–¡“¥â«¬Õ“°“√¢Õß acute visual deficit √à«¡°—∫¡’ photopsia ·≈–æ∫‰¥â∫àÕ¬ „π young myopic female ·μຟâªÉ«¬ MEWDS ®–μ√«® æ∫«à“¡’ white spot ∑’ËÕ¬Ÿà„π√–¥—∫¢Õß outer retina √à«¡ °—∫Õ“®æ∫«à“¡’ vitreous cell, retinal vascular sheathing À√◊Õ optic disc edema √à«¡¥â«¬‰¥â7 „π¢≥–∑’˺ŸâªÉ«¬ AIBSE ®–¡’ blind spot enlargement (√à«¡°—∫ disc edema „π ∫“ß√“¬) ‡ªìπ isolated finding °“√μ√«® FFA ‡æ◊ËÕ¡Õß À“√Õ¬‚√§¢Õß choroid À√◊Õ retina Õ“®™à«¬„π°“√«‘π‘®©—¬ ·¬°‚√§‰¥â¡“°¢÷Èπ
°“√«‘π‘®©—¬ AZOOR ª√–°Õ∫¥â«¬ Õ“°“√¢Õß pho- topsia √à«¡°—∫ acute visual field defect ´÷Ë߇°‘¥®“° §«“¡º‘¥ª°μ‘¢Õß outer retina ‚¥¬∑’Ë°“√μ√«®®Õμ“®– ª°μ‘„π™à«ß·√° ·≈–æ∫«à“¡’ RPE atrophy „πμ”·ÀπàߢÕß ®Õμ“∑’Ë Õ¥§≈âÕß°—∫≈“𠓬μ“∑’˺‘¥ª°μ‘‡¡◊ËÕ‡«≈“ºà“π‰ª5
∂÷ß·¡â«à“ºŸâªÉ«¬∑ÿ°√“¬„π√“¬ß“π©∫—∫π’È®–æ∫«à“Õ“°“√ ¥’¢÷ÈπÀ≈—߉¥â°“√√—°…“¥â«¬ systemic steroid ·μàªí®®ÿ∫—π¬—ß ‰¡à¡’À≈—°∞“π∑’ˇ™◊ËÕ∂◊Õ‰¥â«à“°“√„Àâ ‡μ’¬√Õ¬¥å®–‰¥âª√–‚¬™πå ®√‘ß„πºŸâªÉ«¬ AIBSE ‚¥¬‡¡◊ËÕ¥Ÿ®“°√“¬ß“πºŸâªÉ«¬∑’˺à“π¡“ æ∫«à“ ‚√§π’È “¡“√∂¥’¢÷Èπ‡Õ߉¥â‚¥¬‰¡àμâÕß„Àâ°“√√—°…“„¥Ê1-3
√«¡∂÷ß®“°ª√–«—μ‘„πºŸâªÉ«¬√“¬∑’Ë 2 ®–‡ÀÁπ‰¥â«à“√–¥—∫ “¬μ“ ·≈–≈“π “¬μ“ ‡≈«≈ßÀ≈—ß®“°‰¥â√—∫°“√√—°…“¥â«¬ ‡μ’¬√Õ¬¥å „π√–¬–·√°
‡Õ° “√Õâ“ßÕ‘ß 1. Miller NR. The big blind spot syndrome: unilateral optic disc
edema without visual loss or increased intracranial pressure. In: Smith JL, editor. Neuro-ophthalmology Update. New York: Masson Pub, 1977:163-9.
2. Rosenberg ML, OûConnor P, Carter J. Idiopathic unilateral disc edema. J ClinNeuroophthalmol 1984;4:181-4.
3. Fletcher WA, Imes RK, Goodman D, Hoyt WF. Acute idiopathic blind spot enlargement. A big blind spot syndrome without optic disc edema. Arch Ophthalmol 1988;106:44-9.
4. Volpe NJ, Rizzo JF III, Lessell S. Acute idiopathic blind spot enlargement syndrome. A review of 27 new cases. Arch Ophthalmol 2001;119:59-63.
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5. Watzke RC, Shults WT. Clinical features and natural history of the acute idiopathic enlarged blind spot syndrome. Ophthalmology 2002;109:1326-35.
6. Callanan D, Gass JD. Multifocal choroiditis and choroidal neovascularization associated with the multiple evanescent
white dot and acute idiopathic blind spot enlargement syndrome. Ophthalmology 1992;99:1678-85.
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