Recurrent optic neuritis: clues from a long-term follow up study of recurrent and bilateral optic neuritis patients

Clinical Profile of Optic Neuritis in Malaysian Patients Older Than 45 Years of Age

Introduction

Optic neuritis (ON) is a blinding inflammatory disease of the optic nerve, typically affecting young adults as described in the Optic Neuritis Treatment Trial (ONTT). However, there is limited information describing ON in patients older than 45 years of age. The aim of this study was to determine the clinical profile of ON in this age group in Malaysia.

Methods

A retrospective case series study was performed between January 2014 and December 2018 among patients older than 45 years old, treated as ON in Hospital Universiti Sains Malaysia, Kelantan, Malaysia. Clinical features, visual acuity, imaging, laboratory results, aetiologies, and visual outcomes were analyzed.

Results

This study comprised 17 patients (20 eyes) with a gender distribution of eight males and nine females. The mean age of ON onset was 55.8 ± 7.7 years (46-80 years). Most patients (94.1%) presented with reduced vision and retroorbital pain, and three patients (17.6%) had bilateral eye involvement. Papillitis was observed in 13 eyes (65%), retrobulbar ON in five eyes (25%), and optic atrophy in two eyes. Presenting visual acuity was moderately correlated with final visual outcome (rs= 0.47, n = 20, p < 0.05). Post-treatment visual improvement (good and slight) was reported in 14 eyes (70%), four (20%) had no improvement while the remaining two eyes (10%) had worsening best-corrected visual acuity (BCVA). Infective causes accounted for 23.5% of cases (one ocular syphilis, two ocular tuberculosis, and one case of toxoplasmosis). Most cases (70.6%) were idiopathic ON, and only one case was diagnosed with neuromyelitis optica spectrum disorder (NMOSD).

Conclusion

ON in Malaysian patients older than 45 years of age has no gender predilection and is most likely to be idiopathic; however, infective ON must still be ruled out. Overall visual outcomes were satisfactory. Among the infective causes, ocular tuberculosis caused poor visual recovery as compared with syphilitic and toxoplasmosis-related ON cases.

Clinico-epidemiologic characteristics of optic neuritis in a tertiary eye centre in Eastern India based on the status of serum aquaporin-4 antibody

Purpose:

To elucidate the clinico-epidemiologic characteristics of optic neuritis based on the status of serum aquaporin-4 antibody (AQP4-Ab) in patients with optic neuritis (ON).

Methods:

Medical records of 106 patients with ON and a follow-up of 3 years were reviewed. For each patient, the following data were extracted: medical history, findings of the ocular examination, brain, orbital or spinal MRI, and serological tests for AQP4. The ON was classified as typical or atypical based on disc examination and improvement in vision after intravenous methylprednisolone (IVMP). The clinical findings (typical or atypical), disease course, and outcomes were analyzed according to the serostatus of the ON.

Results:

10 patients ((9.4%) were seropositive for AQP4-Ab; all had atypical ON. 96 patients (91%) were seronegative for AQP4-Ab: 36 atypical ON and 60 typical ON. Profound visual impairment at presentation was seen in all patients. However, at the end of the study period, seropositive and seronegative atypical ON had poor visual outcomes as compared to seronegative typical ON (P = 0.002). Five seropositive and four seronegative patients with atypical ON developed transverse myelitis. Bilateral disease with relapse was more in seropositive patients (80%); however, seronegative with atypical ON also had bilateral presentation and relapse in 42% and 41%, respectively.

Conclusion:

AQP4-Ab seropositive patients mostly present with atypical features such as bilateral recurrent ON, poor visual outcome, and increased incidence of transverse myelitis. However, atypical clinical features can also be seen in seronegative ON with a poor visual outcome and a recalcitrant course.

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.

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.

Recurrent isolated optic neuritis: A study on 22 patients

Background: Isolated relapsing optic neuropathy is a recurrent painful optic nerve inflammation without any sign of other demyelinating diseases such as multiple sclerosis (MS) or neuromyelitis optica (NMO) spectrum disorders, and the attacks are purely responsive to steroid therapy. Methods: Recurrent isolated optic neuritis (RION) was diagnosed in patients who presented with at least two disseminating episodes of optic neuritis, and negative clinical, para-clinical, and radiological features of the demyelinating, infiltrative and vasculitis disorders involving optic nerve. The patients were assigned into two groups, chronic recurrent isolated optic neuritis (CRION) entailing patients with steroid dependent attack of optic neuritis and RION patients without steroid dependent attack of optic neuritis. They were monitored over a median of 4.0 ± 2.5 years. Results: There were 16 women and six men with CRION and RION; with the median age of 31.7 ± 9.8 (29.3 ± 9.7 for women and 37.7 ± 7.7 for men). The women to men ratio was 2.6:1. The mean optic neuritis attack was 2.95 ± 1.32 in total. Eight patients were RION while 14 patients fulfilled CRION criteria and took long term immuno-suppressive drugs. In their follow-up, 4 out of 14 CRION cases (28.5%) showed clinical and concordant para-clinical features of NMO spectrum disorder. The analysis of demographic data showed that the average number of ON attacks in CRION patients (3.79 ± 2.32) was significantly more than the average in patients with RION (2.25 ± 0.46, P = 0.02). Conclusion: CRION is a disease which requires aggressive glucocorticoid and long-term immunosuppressive therapy to restore visual acuity.

[Current recommendations on optic neuritis]

BACKGROUND

The diagnostics and therapy of optic neuritis are complex and require interdisciplinary cooperation.

AIM

Compact, up-to-date recommendations for the clinician appear to be desirable.

MATERIAL AND METHODS

A selective literature search including the authors' professional experience was carried out. An algorithm for the practical approach to optic neuritis was derived from the best available evidence.

RESULTS

Our recommendation distinguishes between compulsory and optional investigations. Differential diagnostic cues with regard to atypical optic neuritis and other optic neuropathies are shown. Standard therapy patterns and means of escalation are suggested. Indications for referral are presented.

CONCLUSION

The algorithm suggested in this article provides ophthalmologists with an effective orientation aid for the complete treatment procedure of optic neuritis.

Chronic relapsing inflammatory optic neuropathy: a systematic review of 122 cases reported

Chronic relapsing inflammatory optic neuropathy (CRION) is an entity that was described in 2003. Early recognition of patients suffering from CRION is relevant because of the associated risk for blindness if treated inappropriately. It seems timely to have a clinical review on this recently defined entity. A systematic literature review, irrespective of language, retrieved 22 case series and single reports describing 122 patients with CRION between 2003 and 2013. We review the epidemiology, diagnostic workup, differential diagnosis, and treatment (acute, intermediate, and long term) in view of the collective data. These data suggest that CRION is a distinct nosological entity, which is seronegative for anti-aquaporin four auto-antibodies and recognized by and managed through its dependency on immuno-suppression. Revised diagnostic criteria are proposed in light of the data compromising a critical discussion of relevant limitations.