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 | *Inflammatory, demyelinating condition of the optic nerve highly associated with MS | ||
**50% will go on to develop MS | **50% will go on to develop MS | ||
*Presenting feature of MS in 15-20% of patients | *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=== | ===Causes=== | ||
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**[[Measles]], [[mumps]], [[varicella zoster virus]], [[EBV]] | **[[Measles]], [[mumps]], [[varicella zoster virus]], [[EBV]] | ||
*Inflammation of structures contiguous with the optic nerve | *Inflammation of structures contiguous with the optic nerve | ||
**Meninges, orbit, sinuses | **[[meningitis|Meninges]], [[orbital cellulitis|orbit]], [[sinusitis|sinuses]] | ||
*Other infections | *Other infections | ||
**[[Syphilis]], [[Tuberculosis]], | **[[Syphilis]], [[Tuberculosis]], [[Cryptococcus]] | ||
*[[Sarcoidosis]], uveitis | *[[Sarcoidosis]], uveitis | ||
*[[Temporal arteritis]] | *[[Temporal arteritis]] | ||
*Vasculitides | *[[vasculitis|Vasculitides]] | ||
*Ischemic optic neuropathy | *Ischemic optic neuropathy | ||
*Hypertensive retinopathy, papilledema | *Hypertensive retinopathy, [[papilledema]] | ||
*[[Diabetes mellitus]] retinopathy | *[[Diabetes mellitus]] retinopathy | ||
*[[Intracranial tumor]], orbital tumor | *[[Intracranial tumor]], orbital tumor | ||
*Glaucoma | *[[Glaucoma]] | ||
==Clinical Features== | ==Clinical Features== | ||
*Acute, usually monocular, vision loss occurring over days (occasionally over hours) | *Acute, usually monocular, [[vision loss]] occurring over days (occasionally over hours) | ||
**May range from mildly reduced to no light perception whatsoever | **May range from mildly reduced to no light perception whatsoever | ||
*Retro-orbital headache | *Retro-orbital [[headache]] | ||
*Pain (esp with eye movement) | *[[eye pain|Pain]] (esp with eye movement) | ||
*Loss of color vision out of proportion to loss of visual acuity | *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> | *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> | ||
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==Evaluation== | ==Evaluation== | ||
===Physical Exam=== | [[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 | *Red desaturation test | ||
**Have patient look with one eye at a dark red object | **Have patient look with one eye at a dark red object | ||
**Test the other eye to see if the object looks the same color | **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 | ***Affected eye often will see the red object as pink or lighter red | ||
*Normal intraocular | *Normal [[intraocular pressure]]s | ||
*Normal slit lamp exam (no evidence of uveitis) | *Normal slit lamp exam (no evidence of uveitis) | ||
*Afferent | *Afferent Pupillary Defect (APD) | ||
*Optic disc swelling and edema (papillitis) | *Optic disc swelling and edema (papillitis) | ||
**Elevated optic nerve disk on [[ultrasound]] = papilledema | **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> | **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=== | ===Work-up=== | ||
*MRI of brain and orbits with gadolinium, plus fat suppression | *[[brain MRI|MRI]] of brain and orbits with gadolinium, plus fat suppression | ||
*CBC | *CBC | ||
*CMP | *CMP | ||
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*RPR, FTABS | *RPR, FTABS | ||
*[[CXR]] | *[[CXR]] | ||
*May consider LP to rule out neuromyelitis optica (Consult with neuro regarding CSF and serum studies): | *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 | **Typically protein/glucose, gram stain/culture, cell count/differential | ||
**Plus angioconverting enzyme, IgG indices, myelin basic protein, oligoclonal bands | **Plus angioconverting enzyme, IgG indices, myelin basic protein, oligoclonal bands | ||
**Plus SERUM IgG indices, oligoclonal bands, angioconverting enzyme, NMO antibodies | **Plus SERUM IgG indices, oligoclonal bands, angioconverting enzyme, NMO antibodies | ||
==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== | ==Disposition== | ||
* | *Admission | ||
==See Also== | ==See Also== | ||
Latest revision as of 13:53, 9 November 2022
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
- More prevalent in populations located at higher latitudes
Causes
- Idiopathic
- Multiple sclerosis
- Postchildhood vaccination
- Viral infection
- Inflammation of structures contiguous with the optic nerve
- Other infections
- 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
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
- ↑ 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/
- ↑ 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.