Atypical Optic Neuritis

The Importance of Optical Coherence Tomography in the Diagnosis of Atypical or Subclinical Optic Neuritis: A Case Series Study

Background: Optic neuritis (ON) is an inflammatory condition of the optic nerve. ON is associated with development of demyelinating diseases of the central nervous system (CNS). CNS lesions visualized by magnetic resonance imaging (MRI) and the finding of oligoclonal IgG bands (OB) in the cerebrospinal fluid (CSF) are used to stratify the risk of MS after a "first" episode of ON. However, the diagnosis of ON in absence of typical clinical manifestations can be challenging. Methods and Materials: Here we present three cases with changes in the optic nerve and ganglion cell layer in the retina over the disease course. (1) A 34-year-old female with a history of migraine and hypertension had suspect amaurosis fugax (transient vision loss) in the right eye. This patient developed MS four years later. Optical coherence tomography (OCT) showed dynamic changes of the thickness of peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) over time. (2) A 29-year-old male with spastic hemiparesis and lesions in the spinal cord and brainstem. Six years later he showed bilateral subclinical ON identified using OCT, visual evoked potentials (VEP) and MRI. The patient fulfilled diagnosis criteria of seronegative neuromyelitis optica (NMO). (3) A 23-year-old female with overweight and headache had bilateral optic disc swelling. With OCT and lumbar puncture, idiopathic intracranial hypertension (IIH) was excluded. Further investigation showed positive antibody for myelin oligodendrocyte glycoprotein (MOG). Conclusions: These three cases illustrate the importance of using OCT to facilitate quick, objective and accurate diagnosis of atypical or subclinical ON, and thus proper therapy.

[Typical and atypical optic neuritis]

Optic neuritis (ON) is one of the most common neuro-ophthalmic causes of vision loss worldwide. Demyelinating ON can be idiopathic or be one of the symptoms of autoimmune demyelinating diseases of the central nervous system (CNS) such as multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). Demographic, clinical and radiological signs of ON in these CNS diseases have differences. In this regard, typical and atypical ON are currently distinguished. Recognizing the clinical features that differentiate typical MS-associated ON from atypical ON in NMOSD and MOGAD is important for choosing the correct disease management and treatment strategy. This review summarizes the data from clinical, laboratory, instrumental methods of management used for the differential diagnosis of optic neuritis.

Clinical spectrum of first episode of optic neuritis in a tertiary care hospital in Southern India - A retrospective analysis

PURPOSE

The purpose of this study was to determine the demographic and clinical patterns of optic neuritis (ON) in patients presenting to a tertiary health-care institute and to study the incidence of multiple sclerosis (MS), magnetic resonance imaging features in varied ON, treatment outcome, and prognosis.

METHODS

A retrospective analysis of patients with first episode of ON presenting to a tertiary care center during the period from March 2013 to March 2021 was done. Details of ocular examination were retrieved from medical records and statistically analyzed.

RESULTS

Three hundred and fifty-four participants with ON were included in this study. The mean age was 40.25 ± 12.2 years. The male: female ratio was 1:1.35. 48.1% had visual acuity of <3/60. Based on clinical presentation, papillitis was seen in 31.5% of subjects, neuroretinitis in 24.1%, and retrobulbar neuritis in 44.4%. Based on etiology, 79.6% were idiopathic, 1.8% presented with infectious ON, and 9.26% were associated with demyelinating disease (MS).

CONCLUSION

Females were predominantly affected. Idiopathic ON formed the major subset etiologically. Sixty-six percent had visual recovery of 6/18 or better following corticosteroid therapy. 9.2% revealed multiple intracranial lesions on neuroimaging, suggesting high association with MS. Therefore, early diagnosis, vigilant monitoring of steroid therapy, and regular follow-up screening for MS remain the mainstay of management in ON.

Characteristics of Lyme optic neuritis: a case report of Lyme associated bilateral optic neuritis and systematic review of the literature

Optic Neuritis is rare in Lyme borreliosis. The current knowledge of optic nerve involvement in Lyme borreliosis relies solely on case reports. The aim of this systematic review was to characterize and investigate the associated factors of optic neuritis in Lyme borreliosis. We further presented a very rare case of isolated bilateral optic neuritis in a Lyme seropositive patient.

Unilateral Acute Idiopathic Optic Neuritis With Superior Altitudinal Visual Field Defect as a Presenting Feature

Patients with acute optic neuritis typically present with acute loss of vision. We describe a case of a young lady of 25 years of age with blurring of vision in the upper visual field of the right eye with otherwise intact visual acuity as the only presenting symptom. Although altitudinal visual field defect is not unknown to be associated with acute optic neuritis, it is generally considered a relatively uncommon occurrence. Our case illustrates an unusually unique occurrence of upper altitudinal visual field defect in association with unaffected visual acuity as the sole presenting symptom of acute idiopathic unilateral optic neuritis. When an altitudinal visual field defect is a presenting feature, besides the usual vascular and compressive causes, optic neuritis should be remembered in the list of differential diagnoses.

Severe Atypical Optic Neuritis in a Patient With Pemphigus Foliaceus on Immunosuppressive Therapy

Bilateral simultaneous acute optic neuritis is a rare occurrence in adults, which has been reported mostly in the setting of untreated systemic autoimmune disorders. Such clinical presentations are encompassed in the spectrum of ‘atypical’ optic neuritis with resultant poor visual outcome and mainly associated with neuromyelitis optica spectrum disorders. We report an unusual presentation, that is, severe atypical optic neuritis in a patient of pemphigus foliaceous on immunosuppressive therapy with significant visual recovery after treatment.

Optic neuritis classification in 2021

Optic neuritis (ON) can be associated with inflammatory disease of the central nervous system or can be isolated, with or without relapse. It can also be associated with infectious or systemic disease. These multiple associations based on a variety of clinical, radiological, and biological criteria that have changed over time have led to overlapping phenotypes: a single ON case can be classified in several ways simultaneously or over time. As early, intensive treatment is often required, its diagnosis should be rapid and precise. In this review, we present the current state of knowledge about diagnostic criteria for ON aetiologies in adults and children, we discuss overlapping phenotypes, and we propose a homogeneous classification scheme. Even if distinctions between typical and atypical ON are relevant, their phenotypes are largely overlapping, and clinical criteria are neither sensitive enough, nor specific enough, to assure a diagnosis. For initial cases of ON, clinicians should perform contrast enhanced MRI of the brain and orbits, cerebral spinal fluid analysis, and biological analyses to exclude secondary infectious or inflammatory ON. Systematic screening for MOG-IgG and AQP4-IgG IgG is recommended in children but is still a matter of debate in adults. Early recognition of neuromyelitis optica spectrum disorder, MOG-IgG-associated disorder, and chronic relapsing idiopathic optic neuritis is required, as these diagnoses require therapies for relapse prevention that are different from those used to treat multiple sclerosis.

Current Recommendations on Optic Neuritis

BACKGROUND

Optic neuritis is a special challenge to the ophthalmologist. It is a relatively frequent condition but difficult to seize morphologically. It has neurological implications and is subject matter of recent trials.

METHODS

Selective literature search including the authors' professional experience.

RESULTS

Practical aids for the ophthalmological management of optic neuritis are derived from the best available evidence and the recent literature is discussed.

CONCLUSIONS

The present paper provides evidence-based recommendations for a safe handling of optic neuritis as well as information on current issues.

Clinical Characteristics of HIV-Associated Optic Neuritis

Introduction

Acute optic neuritis (ON) has been increasingly reported in patients infected with human immunodeficiency virus (HIV). We aimed to describe clinical characteristics of HIV-infected patients with ON.

Materials and Methods

This observational retrospective study was performed from January 2008 to January 2016 in a university hospital in Bangkok, Thailand. Demographic data and clinical manifestations were retrospectively reviewed.

Results

We included 10 HIV-infected patients and divided them into two groups: infectious and non-infectious ON. There were six patients in the infectious ON group (five males, mean age 33.6 years, median CD4 cell counts during ON episodes 36.5 cells/µL, high viral loads, median initial visual acuity [VA] 1.7, median VA difference [initial VA – follow-up VA] 0). Four patients developed cryptococcal meningitis and 2 developed neuro-syphilis. They were treated with amphotericin B plus fluconazole and penicillin G sodium, respectively. There were four patients in the non-infectious ON group (two males, mean age 44.3 years, median CD4 cell count during acute ON 157.5 cells/µL, undetectable viral loads, median initial VA 1.3, and median VA difference 1.2). They were given corticosteroid treatments. There were no statistically significant differences between the two groups with respect to age, sex, and initial VA. There were statistically significant differences in median VA difference and median CD4 cell counts between the two groups (p=0.02 and 0.03, respectively). There was a significant correlation between CD4 counts and duration in three non-infectious ON patients treated with antiretroviral therapy (ART, p<0.001).

Discussion

Patients with infectious ON had low initial CD4 counts and high viral loads. Patients with non-infectious ON had increasing CD4 cell counts and undetectable HIV viral load following ART. The findings are highly suggestive of immune reconstitution inflammatory syndrome. The CD4 cell counts and viral loads may help to identify the type of acute ON in HIV-infected patients and establish proper therapies.

Biologic Therapy in Refractory Non-Multiple Sclerosis Optic Neuritis Isolated or Associated to Immune-Mediated Inflammatory Diseases. A Multicenter Study

We aimed to assess the efficacy of biologic therapy in refractory non-Multiple Sclerosis (MS) Optic Neuritis (ON), a condition more infrequent, chronic and severe than MS ON. This was an open-label multicenter study of patients with non-MS ON refractory to systemic corticosteroids and at least one conventional immunosuppressive drug. The main outcomes were Best Corrected Visual Acuity (BCVA) and both Macular Thickness (MT) and Retinal Nerve Fiber Layer (RNFL) using Optical Coherence Tomography (OCT). These outcome variables were assessed at baseline, 1 week, and 1, 3, 6 and 12 months after biologic therapy initiation. Remission was defined as the absence of ON symptoms and signs that lasted longer than 24 h, with or without an associated new lesion on magnetic resonance imaging with gadolinium contrast agents for at least 3 months. We studied 19 patients (11 women/8 men; mean age, 34.8 ± 13.9 years). The underlying diseases were Bechet's disease (n = 5), neuromyelitis optica (n = 3), systemic lupus erythematosus (n = 2), sarcoidosis (n = 1), relapsing polychondritis (n = 1) and anti-neutrophil cytoplasmic antibody -associated vasculitis (n = 1). It was idiopathic in 6 patients. The first biologic agent used in each patient was: adalimumab (n = 6), rituximab (n = 6), infliximab (n = 5) and tocilizumab (n = 2). A second immunosuppressive drug was simultaneously used in 11 patients: methotrexate (n = 11), azathioprine (n = 2), mycophenolate mofetil (n = 1) and hydroxychloroquine (n = 1). Improvement of the main outcomes was observed after 1 year of therapy when compared with baseline data: mean ± SD BCVA (0.8 ± 0.3 LogMAR vs. 0.6 ± 0.3 LogMAR; p = 0.03), mean ± SD RNFL (190.5 ± 175.4 μm vs. 183.4 ± 139.5 μm; p = 0.02), mean ± SD MT (270.7 ± 23.2 μm vs. 369.6 ± 137.4 μm; p = 0.03). Besides, the median (IQR) prednisone-dose was also reduced from 40 (10-61.5) mg/day at baseline to. 2.5 (0-5) mg/day after one year of follow-up; p = 0.001. After a mean ± SD follow-up of 35 months, 15 patients (78.9%) achieved ocular remission, and 2 (10.5%) experienced severe adverse events. Biologic therapy is effective in patients with refractory non-MS ON.

Atypical optic neuritis - a case with a new surprise every visit

Demyelination is the most common cause of optic neuritis. Typical optic neuritis needs intravenous steroids followed by tapering dose oral steroids. Atypical optic neuritis entails clinical manifestations that deviate from the classic pattern of features. Atypical ON can have devastating visual results if not treated in a timely fashion. Thus, it is critical that cases of atypical optic neuritis are recognized early to initiate proper treatment and preserve vision. Our case presented as an atypical case of optic neuritis. The patient had painless onset and was not responding to steroids, but presentation in the other eye and systemic administration of antivirals helped in management of this case.

Optic Neuropathy Secondary to Polyarteritis Nodosa, Case Report, and Diagnostic Challenges

Purpose

To describe a case of optic neuropathy as a primary manifestation of polyarteritis nodosa (PAN) and discuss diagnostic challenges.

Methods

Case report.

Results

A 41-year-old Hispanic man presented with a 2-day history of reduced visual acuity in his left eye. Physical examination revealed a complete visual field loss in the affected eye. Best-corrected visual acuity (BCVA) in the left eye was hand motion, and fundus examination revealed a hyperemic optic disk with blurred margins, swelling, retinal folds, dilated veins, and normal size arteries. BCVA in the right eye was 20/20; no anomalies were seen during examination of the fundus. The patient was started on oral corticosteroids and once the diagnosis of PAN was made, cyclophosphamide was added to the treatment regimen. Six months later, the patient recovered his BCVA to 20/20 in his left eye.

Conclusion

Rarely does optic neuropathy present as a primary manifestation of PAN; nevertheless, it represents an ophthalmologic emergency that requires expeditious anti-inflammatory and immunosuppressive treatment to decrease the probability of permanent visual damage. Unfortunately, diagnosing PAN is challenging as it necessitates a high index of suspicion. In young male patients who present for the first time with diminished visual acuity, ophthalmologists become cornerstones in the suspicion of this diagnosis and should be responsible for continuing the study until a diagnosis is reached to ensure rapid commencement of immunosuppressive treatment.

Diagnosis and clinical features of common optic neuropathies

Disorders of the optic nerves (optic neuropathies) are some of the most common causes of visual loss, and can present in isolation or with associated neurological or systemic symptoms and signs. Several optic neuropathies-especially inflammatory optic neuropathies-are associated with neurological disorders and thus are often diagnosed and treated by neurologists. The mechanisms underlying optic neuropathies are diverse and typically manifest with decreased visual acuity, altered colour vision, and abnormal visual field in the affected eye. Diagnosis is made on the basis of clinical history and clinical examination, of which several aspects are particularly important, including the mode of onset of visual loss, the presence of pain with eye movements, the visual acuity, and the retention of colour vision. Advances in optic nerve imaging-particularly retinal digital photography, optical coherence tomography, and MRI techniques-have revolutionised the diagnosis and follow-up of patients with an optic neuropathy. Furthermore, improvement and generalisation of some ancillary tests, such as diagnostic antibodies for neuromyelitis optica, allows better phenotyping of the heterogeneous inflammatory optic neuropathies.

The enigma of nonarteritic anterior ischemic optic neuropathy: an update for the comprehensive ophthalmologist

PURPOSE OF REVIEW

Nonarteritic anterior ischemic optic neuropathy (NAION) is the most common cause of acute optic nerve injury, and frequently presents to comprehensive ophthalmologists. We review the typical and atypical clinical features and current literature on various treatment modalities for NAION.

RECENT FINDINGS

The epidemiology and clinical presentation of this disease can be variable, making a definitive diagnosis difficult in many cases. In addition, the differential diagnoses for this disorder, although comprising much less prevalent entities, are quite broad and can have substantial systemic implications if these alternatives go unrecognized. NAION has many systemic associations and comorbidities that deserve inquiry when the diagnosis is made. There are currently no widely accepted, evidence-based treatments for NAION. All recommendations made to patients to reduce their risk of sequential eye involvement, including avoidance of potential nocturnal hypotension, erectile dysfunction medication, and treatment of obstructive sleep apnea, have theoretical bases.

SUMMARY

NAION is a common cause of acute vision loss in adult and older patients, and thus, comprehensive ophthalmologists need to be able to diagnose and appropriately manage this disorder. We anticipate fruitful results from current and future trials aimed at neuroprotection in the affected eye and prevention of sequential eye involvement.