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Oční příznaky Tisk E-mail
Neděle, 30 březen 2008
Roztroušená skleróza (RS) představuje chronické autoimunitní zánětlivé onemocnění centrálního nervového systému (CNS) Ložisko zánětu může vzniknout v kterékoliv oblasti CNS – tedy v mozku včetně zrakového nervu (který je vlastně vývojově výchlipkou CNS a má myelinový obal stejně jako ostatní nervová vlákna CNS) a v míše (obr. 1).
Zánět poškozuje obal nervu tvořený bílkovinou myelinem, může však poškodit i nervové vlákno samé. Podle toho, kterou dráhu zánět postihne, dochází k rozvoji neurologických příznaků – tedy k obtížím, které přivádí pacienta k lékaři.
Oční příznaky u RS mohou být způsobeny jednak postižením kterékoliv části zrakové dráhy, jednak postižením okohybných nervů a center zodpovědných za koordinaci pohybů a orientaci hlavy a těla v prostoru (rovnovážný vestibulární aparát, mozeček a jejich spojení s dalšími centry).
I. porucha zraku způsobená postižením zrakové dráhy
Zraková dráha začíná u specializovaných buněk sítnice – tyčinek (černobílé vidění) a čípků (barevné vidění). Jejich dlouhé výběžky (axony) předávají signál o zrakovém vjemu přes „přepojovací“ bipolární buňky až k buňkám, které označujeme jako gangliové. Výběžky všech gangliových buněk se sbíhají do místa na očním pozadí zvaném papila (obr. 2).
V papile se výběžky spojují do zrakového (též optického) nervu a opouštějí oční kouli směrem do mozku. Hned od místa výstupu z oční koule je oční nerv vybaven myelinovým obalem. Oční nervy se kříží (část vláken z pravého oka se tak dostává do levé poloviny mozku a naopak) a dráha pokračuje až do zrakových center, která jsou uložena v týlním laloku mozku (obr. 3).
Ložisko zánětu může vzniknout v kterékoliv části dráhy – tedy od místa, kde zrakový nerv opouští oční kouli, až po zraková centra v týlní oblasti.
Nejčastěji bývá postižen úsek zrakového nervu za oční koulí, tzv. retrobulbární neuritis (retro – za, bulbus – oční koule, neuritis – zánět nervu) nebo jednoduše optická neuritida, která velmi často bývá také prvním příznakem RS (většinou jednostranně, vzácně oboustranně).
Příznaky optické neuritidy zahrnují náhle vzniklou poruchu zraku – od zamlženého vidění a výpadků zorného pole typicky v jeho centrální části až po úplnou ztrátu zraku na postiženém oku, poruchu barvocitu a bolest za okem hlavně při pohybu oka (oteklý, zánětem postižený nerv tlačí na kostěný kanálek, kterým prochází do lebky).
Výpadky v různých oblastech zorného pole a snížení zrakové ostrosti může být méně často způsobeno i zánětlivým ložiskem v dalších úsecích zrakové dráhy či ve zrakovém centru samém.
Kromě postižení zrakové dráhy vídáme u pacientů s RS také častější výskyt přidruženého autoimunitního nitroočního zánětu – tzv. uveitis.
Nejde přímo o postižení zrakové dráhy, ale o přidružený zánět postihující oční vrstvu živnatky (obr. 4), který se rovněž může projevit poruchou zraku a bolestí. Základním očním vyšetřením lze uveitidu od zánětu očního nervu odlišit.
Oční vyšetření je důležité i k odhalení jiných příčin poruchy zraku u pacienta s RS – šedý zákal (katarakta) nebo zelený zákal (glaukom) patří k možným nežádoucím účinkům dlouhodobého užívání kortikoidů.
Porucha zraku zavede pacienta samozřejmě k očnímu specialistovi – oftalmologovi. K vyšetřením na oftalmologii patří:
1. vyšetření očního pozadí – provádí se přístrojem se zabudovaným zdrojem světla. Paprsek proniká okem a osvětluje oční pozadí – u RS zejména se zaměřením na papilu (obr. 5).
Právě v tomto místě mohou být pozorovány změny typické pro RS.
Aby bylo oční pozadí dobře přehlédnutelné, musí se před vyšetřením navodit rozšíření zorniček (mydriáza) kapkami (tzv. mydriatiky).
Toto rozšíření přetrvává po vyšetření někdy i několik hodin a způsobuje pacientovi problém se zaostřením na blízko.
Vždy se ale vše vrátí do normálu nejpozději do 24 hodin.
V případě akutního zánětu očního nervu bývá nález na očním pozadí zcela normální (říká se, že „nic nevidí lékař ani pacient“), po proběhlém zánětu očního nervu však může být papila nabledlá, protože došlo k úbytku nervových vláken.
2. vyšetření perimetrem je důležité pro vyšetření výpadků zorného pole, které se mohou objevit při zánětu očního nervu. Vyšetření probíhá tak, že pacient sedí před přístrojem, zrakem fixuje určený bod a zaznamenává viditelné záblesky v různých oblastech jeho zorného pole. (Obr. 6)
3. vyšetření zrakových evokovaných potenciálů představuje elektrofyziologickou metodu, která zjišťuje, jak je veden signál celou zrakovou dráhou. Opakování zrakového podnětu (blikání šachovnice na obrazovce) vytváří v odpovídajících částech mozku odpověď, která se snímá elektrodami nalepenými na povrch hlavy. Výsledná křivka může být prodloužena (předpokládáme ztrátu myelinu) nebo snížena ve svých výchylkách – amplitudách (předpokládáme poškození nervových vláken).
4. optická koherenční tomografie (Optical Coherence Tomography, OCT) – nová metoda, která prosvícením oka speciálním paprskem umožňuje neinvazivně proměřit vrstvu nervových vláken na sítnici (retinal nerve fibre layer, RNFL). Takto lze velmi přesně a rychle změřit i místo, kde se nervové výběžky spojují do optického nervu a ještě nejsou obaleny myelinovým obalem – úbytek v této vrstvě přímo odráží úbytek nervových vláken a odpovídá celkovému úbytku mozku – atrofii měřené pomocí magnetické rezonance (MRI).
Poučený oftalmolog samozřejmě pacienta s diagnostikovanou optickou neuritidou odesílá k neurologovi k doplnění MRI a vyšetření mozkomíšního moku s cílem potvrdit nebo vyloučit RS.
Pokud optická neuritida představuje ataku RS, léčba zahrnuje standardní podání methylprednisolonu. Většinou – zejména na začátku choroby – bývá dobrá tendence k úpravě. Zrak se může zcela vrátit do normy, přesto se v některých zátěžových situacích (fyzická námaha, horko) může opět přechodně zhoršit. Hovoříme o tzv. Uhthoffovu fenoménu. Pokud se obtíže do několika hodin upraví, nejde o ataku.
II. porucha zraku způsobená postižením okohybného systému
Přesné a koordinované oční pohyby představují velmi složitý proces, za který zodpovídá několik center mozku. Tato centra zahrnují rovnovážný aparát (vestibulární systém), mozeček, okohybné nervy s jejich jádry a další centra mozkového kmene i dalších struktur CNS.
Jak je popsáno výše, objekt, který chceme sledovat zrakem, registrují tyčinky a čípky na sítnici a předávají signál dále do mozku. V místě, kde je vidění na sítnici nejostřejší (tzv. makula a její střed fovea), je tyčinek a čípků nejvíce. Pokud chceme dobře nějaký předmět vidět, musí se na něj oči zaměřit tak, aby se neustále obrazil právě v místě nejostřejšího vidění. Jakýmkoliv i malým pohybem hlavy se však předmět dostává do oblasti méně ostrého vidění a už ho nevidíme tak jasně. Úkolem okohybného systému je velmi rychle a přesně zareagovat pohybem očí, tím vyrovnat nejrůznější pohyby těla a hlavy a udržet sledovaný obrázek stále na fovee (místě nejostřejšího vidění). Neuvědomujeme si, že bez těchto drobných bezděčných pohybů očí bychom nemohli žádný nápis přečíst při chůzi po ulici (protože se s každým krokem hýbe hlava, a tím i sledovaný nápis).
Porucha kteréhokoliv z výše uvedených center, jejich spojů nebo okohybných nervů může proto způsobit pacientovi obtíže, jako je dvojité vidění a s ním často spojená závrať, kmitání obrazu, cukání očí (tzv. nystagmus), rychlé nekontrolované poskakování očí (opsoklonus) aj.
Řadu z těchto poruch může neurolog nebo oftalmolog zjistit již při pečlivém vyšetření očních pohybů. Jemnější poruchy lze odhalit pomocí elektrofyziologické metody – tzv. elektronystagmografie (ENG). Pacientovi jsou při tomto vyšetření nalepeny malé elektrody na kůži kolem očí. Každý pohyb očí je pak těmito elektrodami zaznamenám a převeden počítačem do křivky. Pacient je usazen do křesla v zatemněné místnosti a sleduje očima bez pohybu hlavou na plátně před sebou světelné body, které se objevují na různých místech plátna, jsou vyšetřovány oční pohyby za pomalého otáčení křesla atd. Tímto vyšetřením lze daleko přesněji odhadnout i postižené místo CNS, které je zodpovědné za okohybnou poruchu.
Akutně vzniklá okohybná porucha bývá u pacienta s RS nejčastěji atakou základního onemocnění a je léčena stejně jako jiné ataky methylprednisolonem. Pečlivé neurologické vyšetření je však vždy na místě, protože může odhalit i jiné příčiny okohybné poruchy a léčba se může lišit. Příkladem je u pacientů s RS častá tzv. benigní polohová závrať. Jde o závrať spojenou s cukáním očí (nystagmem), která se objevuje pouze při určité poloze hlavy (často se objeví třeba při lehu na jednom boku). Problém zde není dán zánětlivým ložiskem RS, ale drážděním krystalků v rovnovážném aparátu vnitřního ucha. Léčba pak na rozdíl od ataky RS nespočívá v podání methylprednisolonu, ale v provedení manévrů s pacientem (přesně dané rychlé změny polohy těla hlavy pacienta prováděné lékařem) s cílem krystalky ve vnitřním uchu dostat z drážděného místa.
MUDr. Eva Krasulová MS Centrum VFN Praha
Obr. 1 převzato a upraveno z www.nationalmssociety.org Obr. 2 převzato a upraveno z www.syberg.be Obr. 3 převzato z www.helpforvisionloss.com Obr. 4 převzato a upraveno z www.amdcanada.com Obr. 5 převzato z Webe re.ophth.uiowa.edu Obr. 6 převzato z www.fnbrno.cz

 
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