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Optic neuritis
From WikEM
Contents
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
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)
- Arteritic anterior ischemic optic neuropathy
- Amaurosis fugax
- Central retinal artery occlusion (CRAO)†
- Central retinal vein occlusion (CRVO)†
- High altitude retinopathy
- Open-angle glaucoma
- Optic neuritis
- Posterior Reversible Encephalopathy Syndrome (PRES)
- Retinal detachment†
- Temporal arteritis†
- Traumatic optic neuropathy
- Vitreous hemorrhage
- Stroke†
†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.
Authors
Kevin Lu, Jordan Swartz, Neil Young, Ross Donaldson, Aaron Snyder, Daniel Ostermayer, Claire
