optic neuritis
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Introduction
Inflammation, demyelination or infection of the optic nerve anterior to the optic chiasm. When the intraocular portion of the optic nerve is involved, the disorder is termed papillitis. If the retina is involved, the disorder is termed optic neuro- retinitis. Otherwise the disorder is termed retrobulbar neuritis.
Etiology
- demyelination
- multiple sclerosis (most common) 28%[7] (generally unilateral)[8]
- Felty's syndrome
- Behr's disease
- Schilder's disease
- metachromatic leukodystrophy
- Brown-Marie syndrome
- encephalomyelitis
- neuromyelitis optica
- inflammation
- infection
- meningitis
- syphilis
- tuberculosis
- mumps
- chicken pox
- Epstein-Barr virus (infectious mononucleosis)
- Herpes zoster
- Lyme disease
- intraocular keratitis
- endophthalmitis
- chronic uveitis
- orbital cellulitis
- orbital abscess (Rollet's syndrome)
- spread of infection from sphenoid & ethmoid sinuses
- HIV1 infection, AIDS
- Mycoplasma
- systemic diseases
- pregnancy
- pharmacologic agents:
- other risk factors
- idiopathic
Epidemiology
- 3-4/100,000 person years
- age 21-30 most common
- female > male[7]
Clinical manifestations
- general
- acute monocular loss of vision (over hours to days)
- loss of color vision affected more severely than visual acuity
- afferent pupillary defect (Marcus Gunn pupil)
- central or paracentral scotoma
- diplopia
- nystagmus
- retrobulbar optic neuritis (multiple sclerosis)
- diffuse swelling of optic nerve
- pain with movement of affected eye
- tenderness on palpation of the globe with the eyelid closed
- ophthalmoscopic examination is normal
- papillitis
- swollen optic disc with blurred margins
- yellow exudate in oval pattern around fovea
- dilated retinal veins
- flame hemorrhages may be present
- inflammatory cells present in vitreous humor
- may progress to optic atrophy with gliosis
- systemic
Laboratory
* distinguishes neuromyelitis optica from multiple sclerosis
Diagnostic procedures
- ophthalmoscopy
- color testing
- visual acuity
- pinhole to assess refractive component
- flashing a light in the eye decreases visual acuity in patients with retinal disease more than in patients with optic neuritis
- visual field testing to identify central scotoma or paracentral scotoma
- swinging light test to detect afferent pupillary defect (Marcus Gunn pupil)
- visual evoked potentials are normal
Radiology
- magnetic resonance imaging of the brain may demonstrate demyelination
- CT of the orbit may demonstrate diffuse swelling of the optic nerve but will not detect demyelination*
* cannot detect multiple sclerosis, so do not order[8]
Differential diagnosis
- optic neuropathy - no early loss of visual acuity
- amaurosis fugax - generally resolves after a short time
- cystoid macular edema
- central serous choroidopathy
- painless loss of vision
- central scotoma
- no afferent pupillary defect
- color vision not severely affected
- papilledema
- no early loss of visual acuity
- tends to be bilateral
- orbital cellulitis
Management
- remove causative factors
- high dose steroids may help some patients
- intravenous methylprednisolone for acute optic neuritis[4]
- not for initial episode; associated with increased risk of recurrence[8]
- IV methylprednisolone 1000 mg equivalent to oral prednisone 1250 mg[6]
- long-term management with glatiramer acetate may prevent progression to multiple sclerosis if demyelination [4]
- intravenous methylprednisolone for acute optic neuritis[4]
- retrobulbar neuritis secondary to demyelination usually resolves spontaneously in 2-6 weeks; some residual optic atrophy may remain
More general terms
More specific terms
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 76-77
- ↑ Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
- ↑ 4.0 4.1 4.2 Medical Knowledge Self Assessment Program (MKSAP) 16, 18. American College of Physicians, Philadelphia 2012, 2018.
- ↑ Beck RW, Cleary PA, Anderson MM Jr et al A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. The Optic Neuritis Study Group. N Engl J Med. 1992 Feb 27;326(9):581-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/1734247
- ↑ 6.0 6.1 Morrow SA, Fraser JA, Day C et al Effect of Treating Acute Optic Neuritis With Bioequivalent Oral vs Intravenous Corticosteroids. A Randomized Clinical Trial. JAMA Neurol. Published online March 5, 2018. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29507942 https://jamanetwork.com/journals/jamaneurology/fullarticle/2673723
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Braithwaite T, Subramanian A, Petzold A et al. Trends in optic neuritis incidence and prevalence in the UK and association with systemic and neurologic disease. JAMA Neurol 2020 Oct 5; 77:1514. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33017023 https://jamanetwork.com/journals/jamaneurology/article-abstract/2771173
- ↑ 8.0 8.1 8.2 8.3 8.4 NEJM Knowledge+ Ophthalmology