Childhood optic neuritis: the pediatric neurologist's perspective

Risk of central nervous system demyelinating attack or optic neuritis recurrence after pediatric optic neuritis in Korea

PURPOSE

To investigate the rate of development of symptomatic central nervous system (CNS) demyelinating attacks or recurrent optic neuritis (ON) after the first episode of ON and its risk factors for Korean pediatric patients.

METHODS

This multicenter retrospective cohort study included the patients under 18 years of age (n=132) diagnosed with ON without previous or simultaneous CNS demyelinating diseases. We obtained the clinical data including the results of neuro-ophthalmological examinations, magnetic resonance images (MRIs), antibody assays, and laboratory tests. We investigated the chronological course of demyelinating disease with respect to the occurrence of neurological symptoms and/or signs, and calculated the 5-year cumulative probability of CNS demyelinating disease or ON recurrence.  RESULTS: During the follow-up period (63.1±46.7 months), 18 patients had experienced other CNS demyelinating attacks, and the 5-year cumulative probability was 14.0±3.6%. Involvement of the extraorbital optic nerve or optic chiasm and asymptomatic lesions on the brain or spinal MRI at initial presentation were significant predictors for CNS demyelinating attack after the first ON. The 5-year cumulative probability of CNS demyelinating attack was 44.4 ± 24.8% in the AQP4-IgG group, 26.2±11.4% in the MOG-IgG group, and 8.7±5.9% in the double-negative group (P=0.416). Thirty-two patients had experienced a recurrence of ON, and the 5-year cumulative probability was 24.6±4.0%. In the AQP4-IgG group, the 5-year cumulative probability was 83.3±15.2%, which was significantly higher than in the other groups (P<0.001).

CONCLUSIONS

A careful and multidisciplinary approach including brain/spinal imaging and antibody assay can help predict further demyelinating attacks in pediatric ON patients.

Pain Symptoms in Optic Neuritis

Signs and symptoms of optic neuritis (ON), an autoimmune disorder of the central nervous system (CNS), differ between patients. Pain, which is commonly reported by ON patients, may be the major reason for some patients to visit the clinic. This article reviews the presence of pain related to ON with respect to underlying disorders, including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein associated disease (MOGAD). The aim of this review is to provide an overview of pain symptoms in accordance with the context of various pathophysiological explanations, assist in differential diagnosis of ON patients, especially at the onset of disease, and make recommendations to aid physicians make decisions for follow up diagnostic examinations.

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.

Update on Pediatric Optic Neuritis

PURPOSE OF REVIEW

The purpose of this review is to provide an update on advances in the understanding of pediatric demyelinating optic neuritis.

RECENT FINDINGS

In the past decade, the disease phenotypes for demyelinating syndromes in children have been more clearly defined. Pediatric optic neuritis may present as a clinically isolated syndrome or in the setting of underlying neurologic disease. In addition to optic neuritis associated with multiple sclerosis or neuromyelitis optica, recent work has identified antibodies to the myelin oligodendrocyte glycoprotein (MOG IgG) as a unique demyelinating cause with distinct features regarding treatment and prognosis. The disease phenotypes for demyelinating pediatric optic neuritis have expanded. Treatment strategies vary and are not universally effective for each cause of demyelinating disease. Accurately distinguishing among these unique clinical syndromes is therefore critical for initiation of appropriate treatment to prevent disability, to maximize visual outcomes, and to provide insight into long-term prognosis.

Clinical Characteristics of Pediatric Optic Neuritis With Myelin Oligodendrocyte Glycoprotein Seropositive: A Cohort Study

BACKGROUND

The clinical characteristics of patients with pediatric optic neuritis with seropositive myelin oligodendrocyte glycoprotein antibodies in Asia have not been reported.

METHODS

Patients ≤18 years-old with acute-onset optic neuritis were enrolled. Serum myelin oligodendrocyte glycoprotein and aquaporin-4 antibodies were detected and patients were followed for at least six months. The clinical features were evaluated among myelin oligodendrocyte glycoprotein-seropositive optic neuritis, aquaporin-4-seropositive optic neuritis, and double seronegative optic neuritis. Best-corrected visual acuity, thickness of optic disc retinal nerve fiber layer, and macular ganglion cell complex were measured by optical coherence tomography.

RESULTS

Among myelin oligodendrocyte glycoprotein-optic neuritis, aquaporin-4-optic neuritis, and seronegative-optic neuritis, the percentages of best-corrected visual acuity measured better than 0.8 (20/25) at the six-month visit were 89.47%, 33.33%, and 82.26%, respectively, a rate that is significantly better in patients with myelin oligodendrocyte glycoprotein-optic neuritis and seronegative-optic neuritis (P = 0.02). The average peripapillary retinal nerve fiber layers were 58.03 ± 8.73 µm, 64.34 ± 12.88 µm, and 78.12 ± 13.34 µm for the patients with myelin oligodendrocyte glycoprotein-optic neuritis, aquaporin-4-optic neuritis, and seronegative-optic neuritis, respectively, which showed no statistical difference between patients with myelin oligodendrocyte glycoprotein-optic neuritis and aquaporin-4-optic neuritis (P = 0.089), but were both thinner than patients with seronegative-optic neuritis (P = 0.001).

CONCLUSIONS

The recovery of visual acuity in patients with myelin oligodendrocyte glycoprotein-optic neuritis was as good as in patients with seronegative-optic neuritis, and the retinal nerve fiber layer of the optic nerve head showed thinning as severe as that of the patients with aquaporin-4-optic neuritis.

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.

Acute onset blindness: a case of optic neuritis and review of childhood optic neuritis

Optic neuritis (ON) is an acquired disorder of the optic nerve due to inflammation, demyelination or degeneration. We report a child who presented with acute onset bilateral visual loss who, following a diagnosis of ON, was treated and had excellent visual recovery. Paediatric ON is considered to be different clinical entity to adult ON. Although in children ON is usually parainfectious or postinfectious, it can be the first presenting feature of multiple sclerosis or neuromyelitis optica spectrum disease. In this paper, we discuss the literature on treatment of ON and prediction of risk of recurrence.

Visual outcomes in pediatric optic neuritis

PURPOSE

To describe the visual outcomes of a large cohort of pediatric patients presenting to a tertiary care pediatric hospital with first-episode optic neuritis.

DESIGN

Retrospective, observational cohort study.

METHODS

In a tertiary care pediatric hospital, patients with first-episode optic neuritis and at least 3 months of follow-up over a 10-year period were assessed and followed-up in the ophthalmology department. The main outcome measures were visual acuity at 3 months and 1 year of follow-up, with analysis of risk factors for poor visual outcomes and the time course of visual recovery.

RESULTS

Of the 59 pediatric patients with first-episode optic neuritis, 46 had at least 3 months of follow-up and 36 had at least 1 year of follow-up. The mean age was 12.6 years old; 72% were female, 41% had bilateral involvement, 52% had or developed an underlying diagnosis (39% multiple sclerosis, 7% acute disseminated encephalomyelitis, 7% neuromyelitis optica), and 91% received treatment (85% steroids, 7% multimodal). At 1 year, 81% were at least 20/20 and 89% were at least 20/40. A poor visual outcome at 1 year (<20/40) was associated with vision of <20/20 at 3 months (P = 0.041). Other clinical characteristics, including visual acuity at presentation, sex, bilateral involvement, optic nerve edema, and underlying diagnoses were not significantly associated with poor visual outcomes.

CONCLUSIONS

In this cohort of pediatric patients with optic neuritis, the majority of patients regained normal visual acuity at 1 year, regardless of baseline clinical characteristics.

Charles Bonnet syndrome after herpes simplex encephalitis

Visual impairment associated with Charles Bonnet syndrome is rarely reported in childhood. We describe a child who presented with visual hallucinations and postinfectious bilateral retrobulbar optic neuritis. The patient had undergone acyclovir therapy for 3 weeks because of herpes encephalitis. Four days after therapy was completed, he experienced visual impairment in both eyes. He manifested a bilateral decrease in visual acuity, with normal funduscopic findings. The patient experienced visual hallucinations for about 1 week, and then experienced total loss of vision. During his hallucinations, the patient did not exhibit behavioral changes or cognitive impairment. The visual hallucinations included unfamiliar children hiding under his bed, and he spoke to someone whom he did not know. Magnetic resonance imaging indicated bilateral optic nerve hyperintensity on T(2)-weighted and contrast-enhanced images. The patient received corticosteroid therapy for his retrobulbar optic neuritis, and his vision returned to normal after 1 month. Although rare, visual impairment can be associated with complex visual hallucinations indicative of Charles Bonnet syndrome.

MR Study of Child Discloses Bilateral Papilledema and Optic Nerve Swelling. CSF Examination Positive for HSV-1 DNA. Could This Be a Rare Primary Manifestation of Herpes Infection?

We describe a rare case of bilateral papilledema and optic nerve swelling in a young patient with bilateral loss of visual acuity five days after onset of muscle contraction and pain involving the neck and right upper and lower limbs. This rare finding may be a possible first manifestation in a human patient of viral disease linked to HSV-1. MR study confirmed edema of the optic disc and evidence of optic nerve swelling. PCR for HSV-1 DNA was positive in the cerebrospinal fluid.

Parent and medical professional willingness to enroll children in a hypothetical pediatric optic neuritis treatment trial

The optic neuritis treatment trial (ONTT) and subsequent studies have had a tremendous impact on the treatment and prognosis of optic neuritis and multiple sclerosis in adults. The results of these studies have been extrapolated to children; however, pediatric data are sparse. Using the method of prospective preference assessment, the willingness of parents and medical professionals to enroll children in a hypothetical Pediatric ONTT was assessed using a mock consent form and questionnaire. A three-arm trial was proposed: (1) intravenous corticosteroids, (2) high-dose oral corticosteroids, and (3) an oral placebo. The forms were completed by 198 parents and 49 physicians. After reviewing the hypothetical scenario, trial design, risks and benefits, and alternatives to the study, 21% of parents would enroll their children in the trial whereas 98% of medical professionals would enroll their patients. With medical professional recommendation, 43% of parents would enroll their children. The manner in which this hypothetical trial was presented to parents, specifically with respect to the recommendation of their child's health care team, influenced a parent's willingness to participate.

Pediatric optic neuritis and risk of multiple sclerosis: meta-analysis of observational studies

PURPOSE

To determine the relationships among age, unilateral versus bilateral simultaneous presentation, magnetic resonance imaging (MRI) lesions, and the risk of multiple sclerosis (MS) in children with optic neuritis.

METHODS

A systematic literature review and meta-analysis were performed by the use of a MEDLINE search to identify published studies containing individual patient data for children with optic neuritis. Age, laterality (unilateral vs bilateral simultaneous optic neuritis), presence of brain MRI abnormalities, and development of MS were recorded. Logistic regression was used to determine the relationships among these parameters.

RESULTS

Fourteen studies met inclusion criteria. Data for 223 patients (age range 2-17.8 years) were analyzed. Unilateral optic neuritis occurred more frequently in older children but was not associated with an increased risk of MS, after adjusting for age (odds ratio [OR] = 1.9, P = 0.11; 95% confidence interval [CI], 0.9-4.3). For every 1-year increase in age, the odds of developing MS increased by 32% (OR = 1.3, P = 0.005; 95% CI, 1.1-1.6, adjusted for the presence of MRI lesions). The risk of MS was greater in children with abnormal brain MRI scans at presentation compared with normal MRIs (OR = 28.0, P < 0.001, 95% CI, 6.3-125.1, adjusted for age).

CONCLUSIONS

The relationship between unilateral and bilateral optic neuritis and the development of MS is dependent on age. Older children and those with brain MRI abnormalities at presentation, are at greater risk for MS. Long-term follow-up of children with optic neuritis is needed to establish the true risk for the development of MS.

Neuromyelitis optica-IgG+ optic neuritis associated with celiac disease and dysgammaglobulinemia: a role for tacrolimus?

We present a pediatric case of recurrent optic neuritis, celiac disease, partial IgA and IgG3 deficiency in the context of anti-aquaporin-4 auto-immunity and familial IgA deficiency with celiac disease. Treatment with tacrolimus was successful in preventing disease relapses. This case stresses the relevance of central nervous system anti-aquaporin-4 auto-immunity in a broader context of immune dysregulation and neuro-immunology.

Magnetic resonance imaging at first episode in pediatric multiple sclerosis retrospective evaluation according to KIDMUS and lesion dissemination in space criteria

BACKGROUND

Several diagnostic imaging criteria are being described and examined in pediatric multiple sclerosis (MS). Compared to adults, children are more likely to experience acute or relapsing demyelinating episodes of various etiologies which show similar clinical and magnetic resonance imaging (MRI) findings.

AIM

To investigate the fulfillment of MRI diagnostic criteria at initial episode in pediatric MS.

METHODS

We reviewed our series of children and adolescents with the final diagnosis of clinically definite MS and applied the McDonald dissemination in space (DIS) and KIDMUS criteria to their initial MRI scans.

RESULTS

Thirty patients (17 girls, 13 boys), most with brainstem dysfunction and polysymptomatic presentation, were included in the study. Twenty-five (83.3%) patients fulfilled both McDonald and KIDMUS criteria. Patients who did not meet any McDonald DIS criteria did not meet KIDMUS criteria either. Only one patient met the McDonald criteria but not the KIDMUS criteria because of the absence of lesions perpendicular to corpus callosum.

CONCLUSIONS

Our results show 5/30 (16.6%) of MS patients may not present the diagnostic MRI features initially. The variable sensitivity observed for the current MRI criteria in different series can be due to referral biases, differences between populations and length of follow-up, and the definition of MS patients by two attacks only.