Risk factors for idiopathic optic neuritis recurrence

Optic Perineuritis Presenting with Transient Monocular Vision Loss (TMVL): Case Report

Optic perineuritis is an inflammatory condition that presents with reduced visual acuity and painful eye movement. The presentation of optic perineuritis is similar of optic neuritis which results in delayed diagnosis and management. Up to this date, we found a single case of optic neuritis that presented with transient monocular vision loss (TMVL). No cases of optic perineuritis were associated with TMVL. Here, we report a case of a 30-year-old woman who presented with recurrent attacks of painless vision loss in her left eye, reaching up to 30 attacks per day. Ophthalmological examination was otherwise unremarkable. Lab investigations were normal. Magnetic resonance imaging was done, which showed left optic nerve sheath enhancement suggestive of left-sided focal optic perineuritis. Patient was managed with 1 mg IV methylprednisolone for 3 days. We report this case to shed light on the importance of accurate and early diagnosis of optic perineuritis presenting with TMVL. Prompt management of optic perineuritis is crucial in reducing morbidity and risk of relapse.

Clinical and radiologic manifestation B-cell mediated autoimmune diseases of central nervous system

B-cell mediated autoimmune diseases of central nervous system (CNS) put a heavy burden on different aspects of society and economy. Taken together, there are different types of autoimmune diseases in which B-cells play an important role and affect CNS in a pattern of inflammation. These diseases have some similarities in clinical presentations and radiological findings and some similarities with other diseases in different aspects such as treatments with each disease having its own characteristics. In this review article, we had a survey on some different types of B-cell mediated autoimmune diseases of CNS and explained how they can be distinguished from each other and how distinct they are according to radiological findings. The aim of this study is to distinguish B-cell mediated autoimmune diseases of CNS from other non-B-cell diseases in order to choose the best anti-B-cell treatments. At the end of this article we briefly explain different types of treatments being utilized and the role of corticosteroids in acute phases of different diseases.

Clinical Features and Outcomes of Pediatric Monophasic and Recurrent Idiopathic Optic Neuritis

Limited data exist on isolated optic neuritis in children. We report the clinical features and treatment of pediatric subjects with monophasic and recurrent idiopathic optic neuritis. This retrospective cohort study of patients with isolated optic neuritis identified 10 monophasic and 7 recurrent optic neuritis cases. Monophasic optic neuritis patients were older (mean 13.3 ± 4.22) than those with recurrent idiopathic optic neuritis (9.86 ± 3.63). Females represented 50% of monophasic and 85.7% of recurrent idiopathic optic neuritis cases. Patients with monophasic optic neuritis were less likely to have a bilateral onset than recurrent idiopathic optic neuritis (40% vs 57.1%). Only 1 case had oligoclonal bands in the cerebrospinal fluid CSF. Most recurrent idiopathic optic neuritis cases had evidence of anti-myelin oligodendrocyte glycoprotein (MOG) antibodies (5/7). Treatment of recurrent idiopathic optic neuritis cases included intravenous pulse glucocorticosteroids and immunotherapy. We observed differences between recurrent and monophasic idiopathic optic neuritis. Immunosuppression appeared to prevent further relapses in recurrent idiopathic optic neuritis patients. Weaning immunotherapies after several years of quiescence in recurrent idiopathic optic neuritis may be possible, but larger studies are needed.

Prognostic Factors for Recovery of Vision in Canine Optic Neuritis of Unknown Etiology: 26 Dogs (2003-2018)

Optic neuritis (ON) is a recognized condition, yet factors influencing recovery of vision are currently unknown. The purpose of this study was to identify prognostic factors for recovery of vision in canine ON of unknown etiology. Clinical databases of three referral hospitals were searched for dogs with presumptive ON based on clinicopathologic, MRI/CT, and fundoscopic findings. Twenty-six dogs diagnosed with presumptive ON of unknown etiology, isolated (I-ON) and MUE-associated (MUE-ON), were included in the study. Their medical records were reviewed retrospectively, and the association of complete recovery of vision with signalment, clinicopathologic findings, and treatment was investigated. Datasets were tested for normality using the D'Agostino and Shapiro-Wilk tests. Individual datasets were compared using the Chi-squared test, Fisher's exact test, and the Mann-Whitney U-test. For multiple comparisons with parametric datasets, the one-way analysis of variance (ANOVA) was performed, and for non-parametric datasets, the Kruskal-Wallis test was performed to test for independence. For all data, averages are expressed as median with interquartile range and significance set at p < 0.05. Twenty-six dogs met the inclusion criteria. Median follow-up was 230 days (range 21–1901 days, mean 496 days). Six dogs (23%) achieved complete recovery and 20 dogs (77%) incomplete or no recovery of vision. The presence of a reactive pupillary light reflex (p = 0.013), the absence of fundoscopic lesions (p = 0.0006), a younger age (p = 0.038), and a lower cerebrospinal fluid (CSF) total nucleated cell count (TNCC) (p = 0.022) were statistically associated with complete recovery of vision. Dogs with I-ON were significantly younger (p = 0.046) and had lower CSF TNCC (p = 0.030) compared to the MUE-ON group. This study identified prognostic factors that may influence complete recovery of vision in dogs with ON. A larger cohort of dogs is required to determine whether these findings are robust and whether additional parameters aid accurate prognosis for recovery of vision in canine ON.

Incidence and Causes of Overdiagnosis of Optic Neuritis

Importance

Diagnostic error is an important source of medical error. Overdiagnosis of optic neuritis may prompt unnecessary and costly diagnostic tests, procedures, and treatments.

Objective

To assess the incidence of and characterize factors contributing to overdiagnosis of acute optic neuritis.

Design, Setting, and Participants

In this retrospective clinic-based cross-sectional study of new patient encounters, 122 patients referred for acute optic neuritis at a university-based Midwestern neuro-ophthalmology clinic between January 2014 and October 2016 were studied. Data were analyzed from September 2016 to July 2017.

Interventions

Definite diagnosis was determined by neuro-ophthalmologists. For patients with alterative diagnoses, the Diagnosis Error Evaluation and Research taxonomy tool was applied to categorize the type of diagnostic error.

Main Outcomes and Measures

The primary outcome was the primary type of diagnostic error in patients erroneously diagnosed as having optic neuritis. Secondary outcomes included final diagnosis and interventions undergone prior to referral.

Results

A total of 122 patients were referred with acute optic neuritis during the study period; 88 (72.1%) were female, and the mean (SD) age was 42.6 (14.0) years. Of these, 49 patients (40.2%; 95% CI, 31.4-49.4) were confirmed to have optic neuritis, and 73 (59.8%; 95% CI, 50.6-68.6) had an alternative diagnosis. The most common alternative diagnoses were headache and eye pain, functional visual loss, and other optic neuropathies, particularly nonarteritic anterior ischemic optic neuropathy. The most common diagnostic error was eliciting or interpreting critical elements of history, which occurred in 24 of 73 patients (33%) with alternative diagnoses. Other common errors included errors weighing or considering alternative diagnoses (23 patients [32%]), errors weighing or interpreting physical examination findings (15 patients [21%]), and misinterpreting diagnostic test results (11 patients [15%]). In patients with alterative diagnoses, 12 (16%) had normal magnetic resonance imaging findings preceding the referral, 12 (16%) had received a lumbar puncture, and 8 (11%) had received unnecessary treatment with intravenous steroids.

Conclusions and Relevance

These data suggest that nearly 60% (95% CI, 50.6-68.6) of patients referred for optic neuritis have an alternative diagnosis, with the most common errors being overreliance on a single item of history and failure to consider alternative diagnoses. Understanding pitfalls leading to overdiagnosis of optic neuritis may improve clinicians' diagnostic process.

Vision-related quality of life and depression in rhegmatogenous retinal detachment patients

The aim of this cross-sectional study is to evaluate vision-related quality of life (VRQoL) and depression in patients with rhegmatogenous retinal detachment (RRD).The VRQoL and depression were evaluated in 58 patients with unilateral RRD and 58 healthy controls, using the Chinese version of the National Eye Institute Visual Function Questionnaire (CHI-VFQ-25) and the Chinese version of Beck Depression Inventory-II, respectively.Composite scores of the CHI-VFQ-25 were significantly lower in the RRD patients, compared with the healthy controls (P < .001). Lower composite scores were associated with older age (P < .01), severer visual loss (P < .05), longer duration of the disease (P < .05), and macular involved (P < .05). The proportion of depression was significantly higher in RRD patients than healthy controls (39.66% vs 5.17%, P < .001). The depression of RRD patients was associated with the longer duration of the disease (r=0.268, P < .001).The RRD patients suffer from poor VRQoL and a high proportion of depression. Physicians should pay more attention to mental health in RRD patients.

Systemic lupus erythematosus and ocular involvement: an overview

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease of undefined etiology and with remarkably heterogeneous clinical features. Virtually any organ system can be affected, including the eye. SLE-related eye involvement can be diagnosed in approximately one-third of the patients and is usually indicative of disease activity. An early diagnosis and the adoption of suitable therapeutic measures are necessary to prevent sight-threatening consequences, especially in patients with juvenile SLE. Periocular lesions, such as eyelid involvement and orbital inflammation, are relatively rare and, in case of orbital masses, may require a biopsy control. Keratoconjunctivitis sicca or secondary Sjögren's syndrome is the most frequent ophthalmic manifestation of SLE. According to its variable severity, lubricating tear drops may be sufficient in mild cases, whereas cyclosporine-A ophthalmic solution, glucocorticoids (GCs), methotrexate, and/or other immunosuppressive drugs may be required in the more severe cases. Partial occlusion of the lacrimal punctum by thermal cautery is rarely applied. Although uncommon, episcleritis and scleritis can sometimes be detected as an initial finding of SLE and reveal themselves as moderate to intense ocular pain, redness, blurred vision, and lacrimation. Unilateral or more often bilateral retinopathy is responsible for visual loss of variable severity and is ascribed to vasculitis of the retinal capillaries and arterioles. In addition to the combined treatment suitable for all patients with active SLE, intravitreal bevacizumab should be considered in cases of severe vaso-occlusive retinopathy and laser photocoagulation in cases of neovascularization. Purtscher-like retinopathy is likely ascribable to the formation of microemboli that results in retinal vascular occlusion and microvascular infarcts. Choroidal disease is characterized by monolateral or bilateral blurred vision. Because of the choroidal effusion, retinal detachment and secondary angle-closure glaucoma may occur. Ischemic optic neuropathy is characterized by acute-onset and progressive binocular visual impairment as a consequence of occlusion of the small vessels of the optic nerves due to immune complex vasculitis. Intravenous GC boluses followed by oral GCs and/or, in case of recurrence, intravenous cyclophosphamide and/or rituximab are commonly employed. Neovascularization can be treated by intravitreal bevacizumab and progression of retinal ischemic areas by retinal laser photocoagulation. Ocular adverse events (AE) have been described following the long-term administration of one or more of the drugs presently used for the treatment of SLE patients. Posterior subcapsular cataracts and secondary open-angle glaucoma are common AE of the prolonged GC administration. The long-term administration of hydroxychloroquine (HCQ) sulfate is well known to be associated with AE, such as vortex keratopathy and in particular the often irreversible and sight-threatening maculopathy. Length of administration > 5 years, > 1000 g total HCQ consumption, > 6.5 mg/kg daily dosing, coexistence of renal disease, and preexisting maculopathy are all considered risk factors for HCQ-induced retinopathy. Ocular AE of additional immunosuppressive and biological agents are still poorly known, given the worldwide more limited experience with their long-term use. A thorough ophthalmological control is strongly recommended at closer intervals for all SLE patients, in step with the total length of exposure to the drugs and the cumulative dose administered.

Optic Neuritis in Korean Children: Low Risk of Subsequent Multiple Sclerosis

BACKGROUND

A relationship between optic neuritis and multiple sclerosis has previously been reported in non-Asian adults. We extended the investigation to Korean children.

OBJECTIVES

We compared the clinical features, laboratory findings, and visual outcomes of optic neuritis between prepubertal children and postpubertal adolescents and evaluated the conversion rate of optic neuritis to multiple sclerosis in Korean children.

METHODS

We conducted a retrospective analysis of children less than 18 years of age presenting with optic neuritis at Pusan National University Hospital between January 2002 and December 2013. Outcomes and clinical, ophthalmologic, magnetic resonance imaging, and laboratory findings were reviewed.

RESULTS

Twenty-six children (male:female, 1:1.2) were included. Follow-up duration was 16.3 ± 27.5 months in the prepubertal children (≤10 years, n = 13) and 8.2 ± 9.2 months in postpubertal adolescent (>10 years, n = 13) (P = 0.32). There was no significant difference between the prepubertal group and postpubertal group in clinical, ophthalmologic, magnetic resonance imaging, or laboratory findings. Of two patients (7.7%) with abnormal brain magnetic resonance images, one developed multiple sclerosis and the other developed acute disseminated encephalomyelitis. Of three patients (11.5%) with relapsing optic neuritis, two developed systemic lupus erythematosus and one developed multiple sclerosis.

CONCLUSION

The risk of developing multiple sclerosis after pediatric optic neuritis was low (7.7%). Abnormal brain magnetic resonance imaging and relapsing optic neuritis should alert the clinician to systemic or neurological disorders.

Elevated Neutrophil Lymphocyte Ratio in Recurrent Optic Neuritis

Purpose. To demonstrate the relation between optic neuritis (ON) and systemic inflammation markers as neutrophil lymphocyte ratio (N/L ratio), platelet count, mean platelet volume (MPV), and red cell distribution width (RDW) and furthermore to evaluate the utilization of these markers to predict the frequency of the ON episodes. Methods. Forty-two patients with acute ON and forty healthy subjects were enrolled into the study. The medical records were reviewed for age, sex, hemoglobin (Hb), Haematocrit (Htc), RDW, platelet count, MPV, white blood cell count (WBC), neutrophil and lymphocyte count, and neutrophil lymphocyte ratio (N/L ratio). Results. The mean N/L ratio, platelet counts, and RDW were significantly higher in ON group (p = 0.000, p = 0.048, and p = 0.002). There was a significant relation between N/L ratio and number of episodes (r = 0.492, p = 0.001). There was a statistically significant difference for MPV between one episode group and recurrent ON group (p = 0.035). Conclusions. Simple and inexpensive laboratory methods could help us show systemic inflammation and monitor ON patients. Higher N/L ratio can be a useful marker for predicting recurrent attacks.

Neurological outcome and predictive factors of idiopathic optic neuritis in China

BACKGROUND

The neurological outcome and predictive factors of idiopathic optic neuritis (ION) in China are largely unknown.

OBJECTIVE

The aim of this paper is to study the neurological outcome of Chinese ION and to investigate the early predictors for multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD).

METHOD

Retrospective medical record review and supplementary follow-up of 107 ION patients was performed. Statistical analysis of the baseline characteristics as risk factors for ION patients converting into MS or NMOSD was performed.

RESULTS

With an average disease course of 9.5years, 19 of the 107 (17.7%) ION patients developed either MS (9, 8.4%) or NMOSD (10, 9.3%). The estimated 5-year and 10-year combined accumulative risk rates were 14.1% and 26.0%, respectively. Significantly higher estimated accumulative conversion risk was found in female versus male (P=0.047), adult versus children (P=0.032), patients with brain MRI lesions versus patients without leasions (P=0.026), patients with CSF positive oligoclonal bands and/or elevated IgG index versus without (P=0.003) and patients with poor visual recovery versus patients with good recovery (P=0.007). Furthermore, brain white matter lesions and good visual recovery were statistically more common typically in MS converters compared with the NMOSD converters (P=0.01 and P=0.006, respectively).

CONCLUSION

The combined conversion rate for ION to MS/NMO in Chinese population was lower than the reported rate for Western countries. In addition to some previously reported high risk factors, white matter lesions on the brain MRI at baseline and good visual recovery were found to be good predictors for Chinese ION converting into MS whereas poor visual recovery with a normal brain MRI suggested a higher likelihood of the ION converting into NMOSD.