Investigation-Directed Approach to Inflammatory Optic Neuropathies

Ocular Syphilis Presenting As Non-arteritic Anterior Ischemic Optic Neuropathy

Syphilis is a sexually transmitted disease caused by the spirochetal bacteria Treponema pallidum. It can cross the blood-brain barrier within days of the infection, causing neurosyphilis and ocular syphilis at any stage of the disease. Ocular syphilis can manifest in any part of the eye but usually as posterior uveitis and pan-uveitis or various types of inflammatory or immune-mediated optic neuritis. Misdiagnosing ocular syphilis as a non-infectious disease has been reported even when seen by ophthalmologists due to the wide variety of possible presentations. In this case report, we describe a case of ocular syphilis that presented with a non-arteritic anterior ischemic optic neuropathy (NA-AION), which to our knowledge, has not been described before in the literature.

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.

Acute Management of Optic Neuritis: An Evolving Paradigm

The current management of acute optic neuritis (ON) is focused on expediting visual recovery through the use of high-dose intravenous corticosteroids. The recent identification of specific autoantibodies associated with central nervous system inflammatory disorders has provided novel insights into immune targets and mechanisms that impact the prognosis, treatment, and recurrence of ON. Therefore, neurologists and ophthalmologists need to be aware of clinical, laboratory, and imaging findings that may provide important clues to the etiology of ON and the potential need for aggressive management. Moving forward, rapid and accurate diagnosis of inflammatory ON will likely be critical for implementing clinical care that optimizes short-term and long-term therapeutic outcomes.

Yield of screening blood work and MRI of the brain and orbits in the work-up of unilateral chronic optic neuropathy

BACKGROUND/OBJECTIVES

No guidelines exist for the investigation of treatable causes of chronic optic neuropathy, including sarcoidosis, lupus, and syphilis. The purpose of this study was to determine the diagnostic yield of screening blood work (ACE (Angiotensin Converting Enzyme) for sarcoidosis, Antinuclear Antibodies (ANA) for lupus, CMIA (chemiluminescence microparticle enzyme immunoassay) for syphilis) and contrast-enhanced MRI brain and orbits in atypical unilateral chronic optic neuropathy.

SUBJECTS/METHODS

Retrospective review from February 2012 to June 2018 at a neuro-ophthalmology practice. Six hundred and eighty-three consecutive charts with optic neuropathy were reviewed. Inclusion criteria were unilateral chronic optic neuropathy and a work-up including contrast-enhanced MRI brain and orbits, CBC, ESR, CRP, ANA, CMIA, and ACE. Exclusion criteria were optic nerve swelling in either eye on initial assessment or an established cause of optic neuropathy. The main outcome measure was diagnostic yield.

RESULTS

Fifty-seven patients were included. One patient had elevated ACE, seven had positive ANA titers, and three had positive CMIA. Zero patients were diagnosed with sarcoidosis, one patient was diagnosed with lupus-related optic neuropathy, and one patient was diagnosed with syphilitic optic neuropathy. The diagnostic yield of ACE was 0%, ANA was 1.75%, and CMIA was 1.75%. MRI revealed planum sphenoidale meningioma causing compressive optic neuropathy in one patient, giving it a diagnostic yield of 1.82%.

CONCLUSION

Routine screening blood work (ACE, ANA, CMIA) and MRI brain and orbits for chronic idiopathic unilateral optic neuropathy has low diagnostic yield, especially if clinical suspicion for syphilis, lupus, and sarcoidosis is low. MRI should still be performed in all cases in order to rule out compressive lesions.

Neuromyelitis Optica Spectrum Disorders: Spectrum of MR Imaging Findings and Their Differential Diagnosis

Neuromyelitis optica (NMO) is an autoimmune demyelinating disorder for which the aquaporin-4 (AQP4) water channels are the major target antigens. Advances in the understanding of NMO have clarified several points of its pathogenesis, clinical manifestations, and imaging patterns. A major advance was the discovery of the AQP4 antibody, which is highly specific for this disorder. Descriptions of new clinical and radiologic features in seropositive patients have expanded the spectrum of NMO, and the term NMO spectrum disorder (NMOSD) has been adopted. NMOSD is now included in a widening list of differential diagnoses. Acknowledgment of NMOSD imaging patterns and their mimicry of disorders has been crucial in supporting early NMOSD diagnosis, especially for unusual clinical manifestations of this demyelinating disease. This pictorial review summarizes the wide imaging spectrum of NMOSD and its differential diagnosis, as well as its historical evolution, pathophysiology, and clinical manifestations. ^©RSNA, 2018.

Ophthalmic and neuro-ophthalmic manifestations of sarcoidosis

PURPOSE OF REVIEW

Sarcoidosis is a multisystemic inflammatory disease that commonly affects the eye and less often the neuro-ophthalmic pathways. The manifestations can be quite variable but can have characteristic signs and clinical features. This review provides a comprehensive overview of the various ocular and neuro-ophthalmic manifestations of sarcoidosis, emerging diagnostic measures and approach to treatment. Particular focus is given to recent advances in diagnostic approach and available treatment options.

RECENT FINDINGS

Laboratory investigations, chest and nuclear medicine imaging remain important techniques for helping to diagnose sarcoidosis. Recent evidence suggests a role for aqueous humor analysis in the diagnosis of ocular sarcoidosis. Characteristic neuroimaging may help differentiate neurosarcoidosis from other causes. The role of blind conjunctival biopsy for suspected neurosarcoidosis is discussed. The emerging role and use of biologics is delineated for the treatment of both ocular and neuro-ophthalmic sarcoidosis.

SUMMARY

Sarcoidosis can affect any part of the visual system: the most common ocular manifestation is uveitis and the most common neuro-ophthalmic manifestation is optic neuropathy. Although diagnosis remains challenging, recent advancements in diagnosis are promising. Emerging biologics with particular efficacy for ocular and neuro-ophthalmic disease provide expanding treatment options for sight-threatening disease.

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.

Retinal Nerve Fiber Layer May Be Better Preserved in MOG-IgG versus AQP4-IgG Optic Neuritis: A Cohort Study

Background

Optic neuritis (ON) in patients with anti-myelin oligodendrocyte glycoprotein (MOG)-IgG antibodies has been associated with a better clinical outcome than anti-aquaporin 4 (AQP4)- IgG ON. Average retinal nerve fiber layer thickness (RNFL) correlates with visual outcome after ON.

Objectives

The aim of this study was to examine whether anti-MOG-IgG ON is associated with better average RNFL compared to anti-AQP4-IgG ON, and whether this corresponds with a better visual outcome.

Methods

A retrospective study was done in a consecutive cohort of patients following anti-AQP4-IgG and anti-MOG-IgG ON. A generalized estimating equation (GEE) models analysis was used to compare average RNFL outcomes in ON eyes of patients with MOG-IgG to AQP4-IgG-positive patients, after adjusting for the number of ON events. The final mean visual field defect and visual acuity were compared between ON eyes of MOG-IgG and AQP4-IgG-positive patients. A correlation between average RNFL and visual function was performed in all study eyes.

Results

Sixteen patients were analyzed; ten AQP4-IgG-positive and six MOG-IgG-positive. The six patients with MOG-IgG had ten ON events with disc edema, five of which were bilateral. In the AQP4-IgG-positive ON events, 1/10 patients had disc edema. Final average RNFL was significantly better in eyes following MOG-IgG-ON (75.33μm), compared to 63.63μm in AQP4-IgG-ON, after adjusting for the number of ON attacks (GEE, p = 0.023). Mean visual field defects were significantly smaller (GEE, p = 0.046) among MOG-IgG positive ON eyes compared to AQP-IgG positive ON eyes, but last visual acuity did not differ between the groups (GEE, p = 0.153). Among all eyes, average RNFL positively correlated with mean visual field defect (GEE, p = 0.00015) and negatively correlated with final visual acuity (GEE, p = 0.00005).

Conclusions

Following ON, RNFL is better preserved in eyes of patients with MOG-IgG antibodies compared to those with AQP4-IgG antibodies, correlating with better visual outcomes.