Optic neuritis: Difference between revisions
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==Background== | ==Background== | ||
*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 | |||
== | ===Causes=== | ||
*Idiopathic | |||
*[[Multiple sclerosis]] | |||
*Postchildhood vaccination | |||
*Viral infection | |||
**[[Measles]], [[mumps]], [[varicella zoster virus]], [[EBV]] | |||
*Inflammation of structures contiguous with the optic nerve | |||
**Meninges, orbit, sinuses | |||
*Other infections | |||
**[[Syphilis]], [[Tuberculosis]], Crypto | |||
*[[Sarcoidosis]], uveitis | |||
*[[Temporal arteritis]] | |||
*Vasculitides | |||
*Ischemic optic neuropathy | |||
*Hypertensive retinopathy, papilledema | |||
*[[Diabetes mellitus]] retinopathy | |||
*[[Intracranial tumor]], orbital tumor | |||
*Glaucoma | |||
== | ==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<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> | |||
== | ==Differential Diagnosis== | ||
{{Acute vision loss noninflamed DDX}} | |||
== | ==Evaluation== | ||
===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 Pupilary Defect (APD) | |||
*Optic disc swelling and edema (papillitis) | |||
**Elevated optic nerve disk on [[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=== | |||
*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 | |||
==Disposition== | ==Disposition== | ||
*Consult neuro and ophthalmology | |||
*Inpatient admission for IV methylprednisolone, 1 g QD x3 days | |||
==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. | |||
[[Category: | [[Category:Neurology]] | ||
[[Category:Ophthalmology]] |
Revision as of 06:54, 15 June 2019
Background
- 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
Causes
- Idiopathic
- Multiple sclerosis
- Postchildhood vaccination
- Viral infection
- Inflammation of structures contiguous with the optic nerve
- Meninges, orbit, sinuses
- Other infections
- Syphilis, Tuberculosis, Crypto
- Sarcoidosis, uveitis
- Temporal arteritis
- Vasculitides
- Ischemic optic neuropathy
- Hypertensive retinopathy, papilledema
- Diabetes mellitus retinopathy
- Intracranial tumor, orbital tumor
- Glaucoma
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)
- Painful
- Arteritic anterior ischemic optic neuropathy
- Optic neuritis
- Temporal arteritis†
- Painless
- Amaurosis fugax
- Central retinal artery occlusion (CRAO)†
- Central retinal vein occlusion (CRVO)†
- High altitude retinopathy
- Open-angle glaucoma
- Posterior reversible encephalopathy syndrome (PRES)
- Retinal detachment†
- Stroke†
- Vitreous hemorrhage
- Traumatic optic neuropathy (although may have pain from the trauma)
†Emergent Diagnosis
Evaluation
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 Pupilary Defect (APD)
- Optic disc swelling and edema (papillitis)
- Elevated optic nerve disk on 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
Disposition
- Consult neuro and ophthalmology
- Inpatient admission for IV methylprednisolone, 1 g QD x3 days
See Also
References
- ↑ 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.
- ↑ 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/
- 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.