Optic neuritis: Difference between revisions

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==Background==
==Background==
[[File:Schematic diagram of the human eye en.png|thumb|Eye anatomy.]]
*Inflammatory, demyelinating condition of the optic nerve highly associated with MS
**50% will go on to develop MS
*Presenting feature of MS in 15-20% of patients
*Female and Caucasian predominance
*Age 20-50 years old
*More prevalent in populations located at higher latitudes


===Causes===
*Idiopathic
*[[Multiple sclerosis]]
*Postchildhood vaccination
*Viral infection
**[[Measles]], [[mumps]], [[varicella zoster virus]], [[EBV]]
*Inflammation of structures contiguous with the optic nerve
**[[meningitis|Meninges]], [[orbital cellulitis|orbit]], [[sinusitis|sinuses]]
*Other infections
**[[Syphilis]], [[Tuberculosis]], [[Cryptococcus]]
*[[Sarcoidosis]], uveitis
*[[Temporal arteritis]]
*[[vasculitis|Vasculitides]]
*Ischemic optic neuropathy
*Hypertensive retinopathy, [[papilledema]]
*[[Diabetes mellitus]] retinopathy
*[[Intracranial tumor]], orbital tumor
*[[Glaucoma]]


-an inflammatory, demyelinating condition highly associated with multiple sclerosis (MS).
==Clinical Features==
*Acute, usually monocular, [[vision loss]] occurring over days (occasionally over hours)
**May range from mildly reduced to no light perception whatsoever
*Retro-orbital [[headache]]
*[[eye pain|Pain]] (esp with eye movement)
*Loss of color vision out of proportion to loss of visual acuity
*Pulfrich effect - swing object side to side like pendulum, but patient feels like the object is coming at them in elliptical fashion; suggestive of demyelination<ref>O'Doherty M and Flitcroft DI. An unusual presentation of optic neuritis and the Pulfrich phenomenon. J Neurol Neurosurg Psychiatry. 2007 Aug; 78(8): 906–907.</ref>


-presenting feature of MS in 15 to 20 percent of patients and occurs in 50 percent at some time during the course of their illness
==Differential Diagnosis==
{{Acute vision loss noninflamed DDX}}


== ==
==Evaluation==
[[File:PMC3379920 jovr-5-3-216-776-1-pbf1.png|thumb|MRI showing enhancement of the left optic nerve, which is typical of optic neuritis.]]
===Diagnosis on Physical Exam===
*Red desaturation test
**Have patient look with one eye at a dark red object
**Test the other eye to see if the object looks the same color
***Affected eye often will see the red object as pink or lighter red
*Normal [[intraocular pressure]]s
*Normal slit lamp exam (no evidence of uveitis)
*Afferent Pupillary Defect (APD)
*Optic disc swelling and edema (papillitis)
**Elevated optic nerve disk on [[ocular ultrasound]] = papilledema
**Increased ON sheath diameter > ~5mm measured 3mm behind globe on US<ref>Shevlin C. Optic Nerve Sheath Ultrasound for the Bedside Diagnosis of Intracranial Hypertension: Pitfalls and Potential. http://www.criticalcarehorizons.com/optic-nerve-sheath-diameter-icp/</ref>


===Work-up===
*[[brain MRI|MRI]] of brain and orbits with gadolinium, plus fat suppression
*CBC
*CMP
*ESR, CRP
*RPR, FTABS
*[[CXR]]
*May consider [[LP]] to rule out neuromyelitis optica (Consult with neuro regarding CSF and serum studies):
**Typically protein/glucose, gram stain/culture, cell count/differential
**Plus angioconverting enzyme, IgG indices, myelin basic protein, oligoclonal bands
**Plus SERUM IgG indices, oligoclonal bands, angioconverting enzyme, NMO antibodies


==Diagnosis==
==Management==
*Consult neuro and ophthalmology with treatment focused on the underlying [[Multiple_sclerosis#Management|MS]]
*IV [[methylprednisolone]], 1 g QD x3 days<ref>Le Page, E. et al. Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP): a randomised, controlled, double-blind, non-inferiority trial. Lancet. 2016 Jan 23;387(10016):340.</ref>


 
==Disposition==
-acute, usually monocular, visual loss-usually monocular (90%)-vision loss (over hours to days; peaking within 1-2 wks)-eye pain (92%), often worsened with eye movement-afferent pupillary defect-visual field defect (typically central scotoma)-papillitis (33%) with hyperemia and swelling of the disk, blurring of disk margins, and distended veins-photopsias (30%) (flickering or flashes of light) often precipitated with eye movement-loss of color of vision out of proportion to the loss of visual acuity is specific ==Work-Up==
*Admission
 
 
Insert ==DDx==
 
 
Insert ==Treatment==
 
 
Insert ==Disposition==
 
 
Insert
 


==See Also==
==See Also==
*[[Multiple Sclerosis (MS)]]


==References==
<references/>
*Petzold A et al. The investigation of acute optic neuritis: a review and proposed protocol. Nat Rev Neurol. 2014 Aug;10(8):447-58.
*Voss E et al. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis. Ther Adv Neurol Disord. 2011 Mar; 4(2): 123–134.


Neuro: Multiple Scleritis
[[Category:Neurology]]
 
[[Category:Ophthalmology]]
 
==Source==
 
 
KajiQuestions
 
 
 
 
[[Category:Ophtho]]

Latest revision as of 13:53, 9 November 2022

Background

Eye anatomy.
  • Inflammatory, demyelinating condition of the optic nerve highly associated with MS
    • 50% will go on to develop MS
  • Presenting feature of MS in 15-20% of patients
  • Female and Caucasian predominance
  • Age 20-50 years old
  • More prevalent in populations located at higher latitudes

Causes

Clinical Features

  • Acute, usually monocular, vision loss occurring over days (occasionally over hours)
    • May range from mildly reduced to no light perception whatsoever
  • Retro-orbital headache
  • Pain (esp with eye movement)
  • Loss of color vision out of proportion to loss of visual acuity
  • Pulfrich effect - swing object side to side like pendulum, but patient feels like the object is coming at them in elliptical fashion; suggestive of demyelination[1]

Differential Diagnosis

Acute Vision Loss (Noninflamed)

†Emergent Diagnosis

Evaluation

MRI showing enhancement of the left optic nerve, which is typical of optic neuritis.

Diagnosis on Physical Exam

  • Red desaturation test
    • Have patient look with one eye at a dark red object
    • Test the other eye to see if the object looks the same color
      • Affected eye often will see the red object as pink or lighter red
  • Normal intraocular pressures
  • Normal slit lamp exam (no evidence of uveitis)
  • Afferent Pupillary Defect (APD)
  • Optic disc swelling and edema (papillitis)
    • Elevated optic nerve disk on ocular ultrasound = papilledema
    • Increased ON sheath diameter > ~5mm measured 3mm behind globe on US[2]

Work-up

  • MRI of brain and orbits with gadolinium, plus fat suppression
  • CBC
  • CMP
  • ESR, CRP
  • RPR, FTABS
  • CXR
  • May consider LP to rule out neuromyelitis optica (Consult with neuro regarding CSF and serum studies):
    • Typically protein/glucose, gram stain/culture, cell count/differential
    • Plus angioconverting enzyme, IgG indices, myelin basic protein, oligoclonal bands
    • Plus SERUM IgG indices, oligoclonal bands, angioconverting enzyme, NMO antibodies

Management

  • Consult neuro and ophthalmology with treatment focused on the underlying MS
  • IV methylprednisolone, 1 g QD x3 days[3]

Disposition

  • Admission

See Also

References

  1. ↑ O'Doherty M and Flitcroft DI. An unusual presentation of optic neuritis and the Pulfrich phenomenon. J Neurol Neurosurg Psychiatry. 2007 Aug; 78(8): 906–907.
  2. ↑ Shevlin C. Optic Nerve Sheath Ultrasound for the Bedside Diagnosis of Intracranial Hypertension: Pitfalls and Potential. http://www.criticalcarehorizons.com/optic-nerve-sheath-diameter-icp/
  3. ↑ Le Page, E. et al. Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP): a randomised, controlled, double-blind, non-inferiority trial. Lancet. 2016 Jan 23;387(10016):340.
  • Petzold A et al. The investigation of acute optic neuritis: a review and proposed protocol. Nat Rev Neurol. 2014 Aug;10(8):447-58.
  • Voss E et al. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis. Ther Adv Neurol Disord. 2011 Mar; 4(2): 123–134.
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