Optic neuritis: Difference between revisions

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
- 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^[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

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.

Authors:

[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/

[1]

[2]

@@ Line 1: / Line 1: @@
 ==Background==
-#an inflammatory, demyelinating condition highly associated with multiple sclerosis (MS)
+*Inflammatory, demyelinating condition of the optic nerve highly associated with MS
-#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
+**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
-==Diagnosis==
+===Causes===
-#acute, usually monocular, visual loss-usually monocular (90%)
+*Idiopathic
-#vision loss (over hours to days; peaking within 1-2 wks)
+*[[Multiple sclerosis]]
-#eye pain (92%), often worsened with eye movement
+*Postchildhood vaccination
-#afferent pupillary defect
+*Viral infection
-#visual field defect (typically central scotoma)
+**[[Measles]], [[mumps]], [[varicella zoster virus]], [[EBV]]
-#papillitis (33%) with hyperemia and swelling of the disk, blurring of disk margins, and distended veins
+*Inflammation of structures contiguous with the optic nerve
-#photopsias (30%) (flickering or flashes of light) often precipitated with eye movement
+**Meninges, orbit, sinuses
-#loss of color of vision out of proportion to the loss of visual acuity is specific
+*Other infections
+**[[Syphilis]], [[Tuberculosis]], Crypto
+*[[Sarcoidosis]], uveitis
+*[[Temporal arteritis]]
+*Vasculitides
+*Ischemic optic neuropathy
+*Hypertensive retinopathy, papilledema
+*[[Diabetes mellitus]] retinopathy
+*[[Intracranial tumor]], orbital tumor
+*Glaucoma
-==Work-Up==
+==Clinical Features==
-Insert
+*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>
-==DDx==
+==Differential Diagnosis==
-Insert
+{{Acute vision loss noninflamed DDX}}
-==Treatment==
+==Evaluation==
-Insert
+===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==
-Insert
+*Consult neuro and ophthalmology
+*Inpatient admission for IV methylprednisolone, 1 g QD x3 days
 ==See Also==
-Neuro: Multiple Scleritis
+*[[Multiple Sclerosis (MS)]]
-==Source==
+==References==
-KajiQuestions
+<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:Neuro]]
+[[Category:Neurology]]
-[[Category:Ophtho]]
+[[Category:Ophthalmology]]