Optic neuritis in children: recurrence and subsequent development of multiple sclerosis

Population-based Incidence of Pediatric and Adult Optic Neuritis and the Risk of Multiple Sclerosis

PURPOSE

To determine the age- and sex-specific prevalence and incidence of demyelinating optic neuritis and the risk of multiple sclerosis (MS) in pediatric and adult populations in South Korea.

DESIGN

A nationwide, population-based, retrospective study using data from the Korean National Health Claims database from 2010 to 2016.

PARTICIPANTS

The entire South Korean population aged 65 years of age or younger (n = 44 700 564). All patients with optic neuritis from the entire Korean population were included.

METHODS

Patients aged 14 years of age or younger were classified as pediatric patients, and those aged 15 to 65 years were classified as adults. Each group was analyzed separately. Patients with optic neuritis had a subsequent diagnosis, including idiopathic, MS, neuromyelitis optica (NMO), and acute disseminated encephalomyelitis. Prevalence and incidence, conversion rate to MS, and treatment modalities (steroids, plasmapheresis, interferon-β, and immunosuppressants) were estimated.

MAIN OUTCOME MEASURES

Prevalence and incidence of optic neuritis, and conversion rate to MS.

RESULTS

Among 44 700 564 individuals, 531 pediatric patients (50.7% female) and 7183 adults (53.3% female) were identified as having optic neuritis. Annual incidence was 1.04 (95% confidence interval [CI], 1.01-1.07) per 100 000 pediatric individuals and 3.29 (95% CI, 3.28-3.30) per 100 000 adults. Peak incidence was observed at 10 to 14 years in the pediatric population and at 30 to 34 years and 50 to 54 years in the adult population. Conversion rate to MS was 13.8% in the pediatric population and 11.4% in the adult population. Fourteen percent of all patients were treated with chronic immunosuppressants, 38% of patients with NMO underwent plasmapheresis, and 50% of patients with MS were treated with interferon-β.

CONCLUSIONS

This is a nationwide epidemiologic study of optic neuritis in individuals of all ages in South Korea. The incidence of optic neuritis and subsequent risk of MS in the pediatric population are comparable to those reported in western countries but are lower in the adult population than in western countries. The incidence rate in adults was 3.2-fold higher than in the pediatric population, and the overall MS conversion rate in the entire Korean population was estimated to be 10.6%.

Pediatric Optic Neuritis: What Is New

Few diseases blur the margins between their childhood and adult-onset varieties as much as optic neuritis. This report will review our state of knowledge of pediatric optic neuritis, as well as its relationship to the latest consensus definitions of neuroinflammatory disease. Current diagnostic and treatment options will be explored, as well as our potential to uncover an understanding of pediatric optic neuritis through systematic prospective studies. The risk of evolving multiple sclerosis is probably less than in adults, but pediatric optic neuritis is more likely to be an initial manifestation of acute disseminated encephalomyelitis. Steroids may hasten visual recovery, but they do not change visual outcome except in cases because of neuromyelitis optica. The role of puberty in modifying the presentation and risk associations is unknown. Prospective studies are required to resolve these diagnostic and management issues.

Pediatric Optic Neuritis

Optic neuritis is rare in children in comparison to adults, but accounts for approximately 25% of pediatric acute demyelinating syndromes. Features of pediatric optic neuritis that differ from adults include a higher rate of bilaterality, poor visual acuity on presentation, and papillitis. Diagnostic work-up includes brain magnetic resonance imaging, lumbar puncture, and blood tests to exclude infectious and inflammatory disorders. Pediatric optic neuritis may occur following infection or vaccination, or in association with a systemic demyelinating process such as acute disseminated encephalomyelitis, neuromyelitis optica, or multiple sclerosis. Treatment is controversial, but most practitioners administer corticosteroids. Most children with optic neuritis experience full visual recovery. The recently launched Pediatric Optic Neuritis Prospective Data Collection Study (PON1) aims to provide estimates of visual acuity outcome and assess the potential to recruit for a future pediatric optic neuritis treatment trial.

Clinical Features and Visual Outcomes of Optic Neuritis in Chinese Children

Purpose. Although optic neuritis (ON) in children is relatively common, visual outcomes and factors associated with the condition have not been well documented. The aim of this study was to evaluate the clinical features and visual outcomes of ON in Chinese children. Methods. Patients with a first episode of ON at a tertiary neuroophthalmic centre in China were assessed and followed up for at least three months. Visual outcomes and clinical, laboratory, and neuroimaging findings were reviewed. In patients with bilateral ON, only the eyes with worse visual acuity (VA) at presentation were used for statistical analysis. Results. Seventy-six children (76 eyes) with a first episode of ON were included. The mean age was 11.8 years, 60.5% were females, and 48.7% had bilateral involvement. The children were followed up for an average of 18.5 months (age range, 3-48 months). Vision loss at presentation was severe, with VA < 20/200 in 37 eyes (48.7%). At the final visit, 3 (3.9%) eyes had VA of at least 20/20, and 41 (53.9%) eyes had VA of at least 20/40. The final VA in 35 eyes (46.1%) was worse than 20/40. Children aged ≤ 10 years had better predicted visual outcomes when compared to children over 10 years (odds ratio = 2.73, 95% confidential interval: 1.05-7.07, and P = 0.039). The other features of this cohort, such as sex, experienced bilateral attack, VA at presentation, presence of optic disc edema, systemic diseases, magnetic resonance imaging (MRI) findings, and aquaporin-4 (AQP-4) antibody status, were not significantly correlated with the final visual outcome. Conclusion. The data revealed the clinical characteristics and visual outcomes of ON in Chinese children. ON in children was associated with severe vision loss and relatively good visual recovery. The age at onset could predict the final visual function.

Optic neuritis in pediatric population: a review in current tendencies of diagnosis and management

Optic neuritis is an inflammation of the optic nerve and may be related to different systemic conditions. The clinical presentation of this pathology usually includes sudden loss of visual acuity (VA) which may be unilateral or bilateral, visual field restriction, pain with eye movements, dyschromatopsia, a relative afferent pupillary defect and optic disk swelling. Optic neuritis in children has specific clinical features and a better prognosis than in adulthood. Although usually appears an underlying viral disease, the main concern for practitioners is the relationship of optic neuritis with multiple sclerosis. In addition to the classical techniques as magnetic resonance imaging (MRI), current tendencies of diagnosis for eye practitioners include new imaging devices as optical coherence tomography (OCT), useful to show a thinning of the retinal fibers layer (RFL) after the inflammatory episode. Regarding the management of these patients, short-term intravenous steroid dosages seem to be the best option to treat acute attacks characterized by a very poor bilateral VA.

Clinical profile of Malay children with optic neuritis

Limited data are available on optic neuritis in Asian children. Clinical profiles tend to vary with different races. We aimed to determine the clinical manifestations, visual outcomes, and etiologies of optic neuritis in Malaysian children, and discuss the literature of optic neuritis in Asian children. A retrospective study involving 14 children with optic neuritis was performed at Hospital Universiti Sains Malaysia between July 2005 and January 2010 (follow-up, 18-60 months). Clinical features, laboratory results, possible etiologies, and visual acuity after 1 year were studied. Females were predominant (mean age at presentation, 11.1 years). All patients manifested bilateral involvement. Swollen optic discs were observed in 92.9% of eyes; 60.7% of patients demonstrated a visual acuity of 6/60 (or 20/200) or worse on presentation, whereas 14.3% remained at 6/60 (or 20/200) or worse, 1 year after their attack. Cecocentral scotoma comprised the most common visual field defect. Infection contributed to 50.0% of cases; 14.3% progressed to multiple sclerosis during follow-up, with no evidence of recurrent optic neuritis. The clinical profiles and etiologies of optic neuritis in Malay children differ slightly compared with other optic neuritis studies of Asian children. The frequency of progression to multiple sclerosis is relatively lower.

The course of early-onset multiple sclerosis in Iraqi children

BACKGROUND

Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system that is increasingly recognized worldwide in children and adolescents. The current study aimed at identifying the clinical characteristics of MS with onset under 18 years of age.

METHODS

This cross-sectional study was conducted in the Multiple Sclerosis Center archive system in Baghdad Teaching Hospital during the period from March 1 to May 15, 2008. The records of 1125 MS patients from 2000 to 2008 were reviewed. Among them 77 patients had the onset of MS under 18 years of age.

RESULTS

Two thirds of the patients were female (a female/male ratio of 1.6:1). The mean age of the patients at the onset of the disease was 14.95 ± 3.21 years, and the mean time between the first and second attacks was 3.06 ± 4.09 years. Seventy patients (90.9%) had an initial course of relapse remitting MS. Among them 9 (12.9%) progressed to secondary progressive MS after a mean duration of 9.87 ± 4.14 years. The remaining 7 patients had primary progressive MS associated with optic neuritis and brain stem lesion. Fifty-nine (76.6%) patients had monofocal signs and 18 (23.4%) had polyfocal signs. The mean extended disability status scale score was 4.15 ± 2.17 and the mean progression index was 1.44 ± 2.31. There was a strong inversed correlation between the progression index and interval between the first and second attacks (P=0.0001).

CONCLUSIONS

The results of the present study show that the course of MS in Iraqi children and adolescents is more aggressive than in children from other countries. This finding needs to be evaluated by further studies.

Clinical characteristics of optic neuritis in Taiwanese children

PURPOSE

To document the etiology, clinical presentation, and visual prognosis of optic neuritis in Taiwanese children.

METHODS

Retrospectively reviewed children younger than 18 years old with optic neuritis in Chang Gung Memorial Hospital and Chang Gung Children's Hospital from 1998 to 2009.

RESULTS

There were 24 children (38 eyes) with optic neuritis in that period. Overall, 14 patients (58.3%) were female and 10 patients (41.7%) were male. In total, 14 patients (58.3%) had bilateral involvement, and 10 patients (41.7%) had unilateral involvement. Out of 38 eyes, 24 (63.2%) had disc swelling. Out of 24 patients, 21 (87.5%) underwent intravenous steroid therapy (10 to 30 mg/kg/day) for 3-5 days, and followed by an oral taper. Out of 24 patients, 20 (83.3%) achieved final visual acuity (VA) of 20/40 or better. However, a poor visual outcome (four patients) (VA<20/40) was correlated with pale disc at presentation (P=0.002, Pearson χ (2)-test) and age older than 10 years (P=0.012, Fisher's exact test). Five patients were diagnosed with acute disseminated encephalomyelitis (ADEM) (21%), and three patients were diagnosed with multiple sclerosis (MS) (12.5%). Patients with ADEM did not have a better visual outcome than patients with MS (P=0.643, Fisher's exact test).

CONCLUSIONS

Visual recovery from optic neuritis was favorable in Taiwanese children. A poor visual outcome was correlated with pale disc at presentation and patients' age older than 10 years. ADEM is the most common associated systemic disease; MS is relatively rare.

Acute disseminated encephalomyelitis: a 10-year cohort study in Thai children

Childhood acute disseminated encephalomyelitis (ADEM) is a demyelinating disease with variable clinical courses and outcomes. Its evolution to multiple sclerosis in Asian children is yet to be determined. Medical records, investigation results and magnetic resonance imaging of brain of Thai children aged less than 15 years with initial diagnosis of ADEM at a referral university hospital in Thailand from January 1997 to December 2006 were reviewed. Clinical course and the outcome were finalized by telephone interview, self-report questionnaire, and/or neurological examination by December 2008. Modified Rankin Score was applied for determination of disability. MRI findings were categorized along with the locations and number of areas of abnormalities shown by T2-weight and FLAIR. 16 patients consisting of 5 boys and 11 girls (age-range 1-14 years, mean 6.9 ± 3.6 years, median 6 years) were identified. Nine patients had cranial nerve dysfunctions including one child with optic neuropathy. One patient died with confirmed pathological diagnosis of ADEM. Among the remaining 15, who were followed from 2 to 10 years (mean 5.8 years), 13 and 3 patients were classified into monophasic ADEM and multiple sclerosis, respectively. Ten of 13 with final diagnosis of ADEM had complete recovery. There was no association between number of lesions or location in the initial MRI and the outcome and final diagnosis. ADEM in Thai children had similar clinical presentation and outcome to previous studies in Western countries. ADEM can occasionally evolve to multiple sclerosis in Thai children as being shown in previous reports from other Asian countries.

Childhood optic neuritis: the pediatric neurologist's perspective

BACKGROUND

Optic neuritis in children may be an isolated, usually postinfectious event, or the symptom of a more widespread disorder.

AIM

To investigate the etiological spectrum of optic neuritis in children in association with diagnostic findings and follow-up results.

METHODS

We retrospectively examined the records of 31 children aged 4-15 (mean 9.7+/-2.9) years in whom isolated optic neuritis was the presenting neurological symptom.

RESULTS

Monophasic bilateral optic neuritis was the most common presentation (45%), followed by the unilateral (32%) and recurrent (22%) forms. Initial cranial MRI was abnormal in 12/31 patients. During a mean follow-up of 2.2 years (6 months-15 years), 6/14 bilateral cases, 9/10 unilateral and 5/7 recurrent cases were diagnosed with various disorders including total eight with MS. The MS group tended to start with unilateral optic neuritis, was older (mean 11.6+/-1.5 vs. 8.8+/-2.9 years), and included more girls than the other groups.

CONCLUSIONS

Optic neuritis in children is frequently part of a systemic or neurological disorder even in the presence of normal cranial imaging. These patients should be evaluated and followed-up in pediatric neurology clinics.

Clinical characteristics of multiple sclerosis and associated optic neuritis in Korean children

PURPOSE

To study the clinical characteristics of multiple sclerosis and associated optic neuritis in Korean children.

METHOD

A retrospective analysis was performed on 10 patients with an onset of multiple sclerosis before age 16. Information on sex, age of onset, clinical course, laboratory findings, and clinical characteristics of optic neuritis was obtained.

RESULT

The mean age at presentation was 7.31 +/- 2.99 years, and the mean duration of observation was 36.2 +/- 26.1 months. No female predilection (50%) was observed. The disease presented as relapsing-remitting type multiple sclerosis in all patients and transited to secondary progressive type in two cases (20%). No oligoclonal bands were found in any patient. Optic neuritis occurred in eight patients (80%); five (62.5%) of these had optic neuritis at the first multiple sclerosis attack, with all five manifesting bilateral simultaneous optic neuritis. Visual acuity recovered to > or =20/40 in 8 of 15 eyes (53.3%), but in 2 eyes (13.3%) visual acuity remained at < or =20/200. In the patients with optic neuritis, the patients who showed optic neuritis at initial presentation had a worse visual prognosis (p = 0.030, Mann-Whitney U-test).

CONCLUSIONS

In Korean children with multiple sclerosis, age of onset was younger than reported in other countries, and there was no female predominance. The prognosis for good visual acuity was worse in patients who initially presented with optic neuritis.

Multiple sclerosis in children: clinical diagnosis, therapeutic strategies, and future directions

The onset of multiple sclerosis (MS) in childhood poses diagnostic and therapeutic challenges, particularly if the symptoms of the first demyelinating event resemble acute disseminated encephalomyelitis (ADEM). MRI is an invaluable diagnostic tool but it lacks the specificity to distinguish ADEM from the first attack of MS. Advanced MRI techniques might have the required specificity to reveal whether the loss of integrity in non-lesional tissue occurs as a fundamental feature of MS. Although the onset of MS in childhood typically predicts a favourable short-term prognosis, some children are severely disabled, either physically or cognitively, and more than 50% are predicted to enter the secondary-progressive phase of the disease by the age of 30 years. Immunomodulatory therapies for MS and their safe application in children can improve long-term prognosis. Genetic and environmental factors, such as viral infection, might be uniquely amenable to study in paediatric patients with MS. Understanding the immunological consequences of these putative exposures will shed light on the early pathological changes in MS.

Clinical characteristics of Japanese children with optic neuritis

The clinical characteristics of children with optic neuritis have been reported to be different from that of adults and to vary among different races. To determine the clinical characteristics of Japanese children with optic neuritis, we examined the medical records of 41 children who were diagnosed with optic neuritis at the Department of Ophthalmology of Chiba University Hospital between January 1979 and December 2001. Information on the sex, age of onset, laterality, initial visual acuity, final visual acuity, recent infections and immunizations, and presence of systemic neurologic diseases, such as multiple sclerosis or acute disseminated encephalomyelitis, was obtained. These findings revealed that the clinical features of optic neuritis in children were similar to those reported earlier. The percentage of optic neuritis cases that developed multiple sclerosis in children was similar to that for children in Europe and North America, and this percentage was not lower than that in adults in our clinic. These findings can be taken as the characteristics of optic neuritis of children in Japan.

Optic neuritis in children--clinical and electrophysiological follow-up

Optic neuritis (ON) in children usually presents with visual loss, relative afferent pupillary defect (RAPD), abnormal optic disc appearance, defects of visual field and colour vision, as well as with abnormalities of visual evoked potentials (VEP). Both, clinical and VEP parameters, improve after the attack; the time until recovery, however, is as yet unknown. The aim of this study was to follow-up children with ON for 1 year and to determine clinical and VEP recovery. Twelve children (six with bilateral, six with unilateral ON) were studied in the acute phase and systematically followed-up for 1 year. The results show that initially, visual acuity was diminished in all eyes, while after 1 year, in only 14% of them. Optic disc appearance was abnormal in 83.3% of the eyes in the acute phase, and in 85% after 1 year. At the disease onset RAPD could be detected in 67%, visual field defects in 58.5%, and colour vision defects in 50% of eyes, but none of these abnormalities persisted in any eye until the end of study. VEP were abnormal in 83% of eyes in the acute phase and in 56% at the final follow-up (at 6 or 12 months). VEP normalization, when occurred, was mostly observed during the first 6 months. Complete clinical and VEP recovery was observed in three children. Both, clinical and electrophysiological recovery in children with ON were relatively substantial and fast within the first year. VEP improvement may indicate better prognosis.

Childhood autoimmune neurologic diseases of the central nervous system

An autoimmune mechanism for ADEM and MS can be supported by the similar patterns of pathologic changes seen in both diseases with the animal model EAE induced by inoculating animals with nervous tissue and the occurrence of ADEM in patients exposed to nervous tissue during vaccination. Whereas there are no universally agreed-upon criteria for the diagnosis of ADEM, a combination of prodromal illness or preceding vaccination, MRI signs of demyelination, and an acute presentation of neurologic symptoms are the triad most commonly looked for in making the diagnosis of ADEM. An ever-increasing number of infections and vaccinations (nonspecific URIs being most common) has been associated with ADEM. Fever and encephalopathy are seen frequently at presentation. Seizures also are common, as are cranial nerve abnormalities and motor symptoms. A mild pleocytosis or protein elevation is found in the majority of patients with ADEM. Intrathecal IgG synthesis and oligoclonal bands are relatively infrequent but should not be considered inconsistent with the diagnosis of ADEM. White matter changes on T2 in a bilateral although asymmetric distribution with relative sparing of the periventricular region with or without deep gray matter involvement is consistent and to some a requirement for the diagnosis. Low-dose steroids have no beneficial effect in the treatment of ADEM and may be contraindicated. High-dose steroids may have a beneficial effect, particularly in more prolonged illnesses, although the evidence is primarily anecdotal. If steroids are used to improve morbidity, 30 mg/kg/d of methylprednisolone for three to five days is the dose with a six-week taper to reduce the risk of recurrence. The prodromal infection may be a major factor in the ultimate mortality and morbidity of the disease. The current mortality of ADEM is quite low. Whether or not this is an effect of different triggering agents or changes in medical care cannot be determined. In larger series of patients with ADEM, 10% to 20% of children experience some sort of recurrence with the majority occurring in the initial one to two months after the first event. This is sometimes associated with steroid withdrawal. A second group of children have a late second recurrence that clinically may not be MS but a recurrence of ADEM, although longer follow-up may change that assessment. Two months should be allowed before a second relapse is considered a manifestation of MS, whereas a second attack also may occur years after an initial attack of ADEM and still be consistent with ADEM recurrence. MS does occur during childhood, with the youngest children at the least risk, and risk increasing with age. The criteria of Poser et al can be used to diagnose MS in childhood [40]. The presentation of MS in childhood is most often sensory, motor, and brainstem signs and symptoms. A relapsing-remitting course is most common with a first relapse occurring in the year after presentation. MRI findings in MS typically show periventricular changes. Oligoclonal bands and CSF IgG synthesis are found in the majority. Treatments of childhood MS have not been studied adequately, but, when treatments studied in adults are used in children, they are well tolerated. Efficacy has not been shown. The long-term outcome of MS in childhood can be either severe or benign with no clear consensus that childhood MS is either a less or more severe disease than the adult form. ATM and ON treatments and outcomes are particularly difficult to evaluate because of the heterogeneity of populations included in case series and the small numbers reported. Steroids are used with anecdotal reports of their superiority to nontreatment. Outcome in ATM often can be poor, whereas in ON it rarely is. A multinational collaborative effort to study and collect the large numbers necessary to address the important questions in these childhood autoimmune disorders would be of great benefit and the only way likely to demonstrate good evidenced-based medicine practiced in this field.

Optic neuritis in Asian children

PURPOSE

To study the clinical spectrum of pediatric optic neuritis in Korean children.

METHODS

A retrospective analysis was performed on 23 patients with onset of the disease before the age of 16 years from 1995 to 2000. The degree of initial visual loss, subsequent visual recovery, magnetic resonance images, and associated diseases was reviewed.

RESULTS

There was no female predilection in the study group (43%) with a mean age of 8.9 years at presentation. Involvement was bilateral in 87% of patients. A preceding febrile illness within 2 weeks of visual symptoms was reported in 39% of patients. Of the 43 involved eyes of 23 patients, disc swelling was present in 51%, and central/cecocentral scotoma in 58% of the involved eyes. With a mean follow-up of 14 months, 79% of the patients had final vision of > or =20/40. Twenty-four (96%) of 25 eyes with intravenous steroid treatment and 10 (56%) of 18 eyes without intravenous steroids showed final visual acuity > or =20/40. Only 1 patient (4%) with multifocal signal abnormalities around the periventricular white matter developed multiple sclerosis.

CONCLUSION

Korean children with optic neuritis showed bilateral involvement with papillitis. The visual prognosis was relatively good and especially better in the patients receiving intravenous steroid treatment than in those without any treatment; however, this study is not controlled. Although a longer follow-up period is required, the development of multiple sclerosis is rare in Korean children with optic neuritis.