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A 24-year-old woman with blurred vision and eye pain
Digital Journal of Ophthalmology 2008
Volume 14, Number 16
August 18, 2008
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Aristeidis Konstantinidis | Royal United Hospital Bath, UK
Ioannis Athanasiadis | Milton Keynes General Hospital, UK
Nikolaos Kozeis | Hippokarateio General Hospital , Greece
Claire Workmann | Coventry & Warwickshire University Hospital, UK
Yajati Ghosh | Coventry & Warwickshire University Hospital, UK
Diagnosis and Discussion
The most common process affecting the optic chiasm is a compressive lesion such as tumor, aneurysm, arachnoid cyst, or hydrocephalus. More rare etiologies include demyelination, vasculitis (e.g. systemic lupus erythematosus), inflammation (e.g. sarcoidosis), trauma, vitamin B12 deficiency and empty sella syndrome.(4,5,6). Other authors have described patients with chiasmal visual field defects in whom MS was either the definitive or most likely diagnosis.(4,7) None of the patients described a junctional scotoma associated with typical multiple sclerosis findings of periventricular white matter and chiasmal lesions showing enhancement with gadolinium, without the presence of RAPD. Our patient was eventually diagnosed with MS based on a new attack in her lower extremities, which occurred several months after her initial ocular complaints. In addition, she had CSF studies, which demonstrated oligoglonal bands and lymphocytosis.

The knee of Wilbrand which was initially described by Hermann Wilbrand (8,9) is believed to be made up of crossing fibers that originate from the inferonasal retina (superotemporal visual field), which travel for a short course in the posterior segment of the contralateral optic nerve before they loop back in the contralateral optic tract. As the presence of a RAPD implies an asymmetry of light input between the two eyes, it is likely that the difference in the number of optic nerve fibers affected in the two eyes of our patient was not as great as to clinically produce a RAPD.

The existence of Wilbrand’s knee has been disputed (10) and recent sophisticated studies have not confirmed its presence either in humans or other primates.(11) Despite these findings the junctional scotoma remains a classic example of damage to the optic chiasm.(12,13,14) Neurological and radiological investigations are warranted in a case presenting with junctional scotoma in order to identify the nature of the lesion.