Optic neuritis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Historical Perspective

Discovery

Classification

Optic neuritis may be classified into atypical or typical subtypes based on its clinical features.[2]

  • Atypical optic neuritis entails clinical manifestations that deviate from classic pattern of optic neuritis features.[3]
  • Atypical features to consider include:[3]
    • Lack of pain
    • Simultaneous or near-simultaneous onset
    • Lack of response to or relapse upon tapering from corticosteroids
    • Optic neuritis due nerve head or peripapillary hemorrhages

Pathophysiology

Pathogenesis

Causes

The following autoimmune are associated with optic neuritis:[7][8][9]

Differentiating Optic Neuritis from other Diseases

Optic neuritis must be differentiated from other diseases that cause sudden eye pain and vision loss such as:[2]

  1. Leber’s Hereditary Optic Neuropathy (LHON)[2] which results from point mutations in mitochondrial DNA and subsequent mitochondrial dysfunction, causing bilateral central vision loss.[10]
  2. Nonarteritic Anterior Ischemic Optic Neuropathy (AION)[2]

Epidemiology and Demographics

Incidence

  • The incidence of optic neuritis is approximately 5 to 6.4 per 100 000 individuals in US.[7][11][12]

Age

  • Optic neuritis commonly affects patients between the ages of 15 and 49.[13]

Race

  • Optic neuritis usually affects individuals of the Caucasians race eight times more frequently than Blacks and Asians.[7][14][15][16]
  • Black populations individuals are less likely to develop optic neuritis.[7][14][15][16]

Gender

  • Women are more commonly affected by optic neuritis than men.[2]

Region

  • The incidence of optic neuritis is highest in populations located at higher latitudes such as:[7][17][18]
    • Northern United States
    • Northern and Western Europe
    • New Zealand and Southern Australia

Risk Factors

Common Risk Factors

Natural History, Complications and Prognosis

Natural History

  • The symptoms of optic neuritis usually develop in the second decade of life, and start with symptoms such as pain on movement of the eyes, followed by a worsening of vision.[28]
  • Common symptoms of optic neuritis include:[28][29]
    1. Pain on movement of the eyes which is sever and so disturbing
    2. Seeing things darkly, unclearly, and with poor contrast
    3. Dirty and pale Colors
    4. Visual field loss
    5. Disturbed color vision
    6. Flashing lights
  • After a sub acute onset, the patient’s visual acuity continues to deteriorate for a few more days; in the untreated course of the disease, it generally reaches its nadir in one to two weeks and then improves again.[28]

Complications

Prognosis

  • The long-term visual prognosis of idiopathic optic neuritis is generally good.[31]
  • More than 90% of the patients recover a visual acuity of 20/40 or better by 6 months.[31]
  • Findings associated with poor visual outcome at 6 months include:[32][31]
    • A cut-off level of vision ≤ 20/50
    • Contrast sensitivity of <1.0 log units
    • A visual field mean deviation of ≤ – 15 dB after 1 month in the Optic Neuritis Treatment Trial.
  • Despite the relatively good visual outcome, most patients show a degree of long-lasting damage to the optic nerve, such as:[31]

Diagnosis

Diagnosis studies

The diagnosis of typical optic neuritis is usually made clinically.[2]

The classic triad for diagnosis of optic neuritis consist of:[2][17][33]

  1. Visual loss
  2. Periocular pain
  3. Dyschromatopsia

MRI is the diagnosis study of choice for visualising the optic nerve.

The following result of MRI is confirmatory of optic neuritis:

  • Swollen retrobulbar intra-orbital segment of the optic nerve with a high T2 signal. High T2 signal persists and may be permanent;
  • Atrophied nerve in chronic cases

Other diagnosis studies which may help to diagnosis of optic neuritis include:[34][35][36]

Symptoms

  • The symptoms of optic neuritis usually develop in the second decade of life, and start with symptoms such as pain on movement of the eyes, followed by a worsening of vision.[28]
  • Common symptoms of optic neuritis include:[28][29][37]
    1. Pain on movement of the eyes which is sever and so disturbing
    2. Seeing things darkly, unclearly, and with poor contrast
    3. Dirty and pale Colors
    4. Visual field loss
    5. Disturbed color vision
    6. Flashing lights
  • After a sub acute onset, the patient’s visual acuity continues to deteriorate for a few more days; in the untreated course of the disease, it generally reaches its nadir in one to two weeks and then improves again.[28]

Physical Examination

Physical examination of patients with optic neuritis is usually remarkable for:[2][17][9]

Laboratory Findings

Imaging Findings

Among all imaging studies, MRI is the diagnosis study of choice for visualising the optic nerve.

The following result of MRI is confirmatory of optic neuritis:

  • Swollen retrobulbar intra-orbital segment of the optic nerve with a high T2 signal. High T2 signal persists and may be permanent;
  • Atrophied nerve in chronic cases

Other diagnosis studies which may help to diagnosis of optic neuritis include:[34][35][36]

Other Diagnostic Studies

There are no widely used other diagnosis studies for diagnosis of optic neuritis.

Treatment

Medical Therapy

Optic neuritis requires prompt treatment.

The mainstay of treatment for optic neuritis is corticosteroid therapy and is recommended among all patients who develop optic neuritis.[28]

Some pharmacologic medical therapies for optic neuritis include:[28]

  1. Oral prednisone treatment at a dose of 1 mg/kg body weight /day for 14 days
  2. intravenous methylprednisolone treatment at 500–1000 mg/day for 3_5 days followed by oral prednisolone (1 mg/kg BW) for 11 days

Surgery

  • In the case of optic canal compression in patients with severe optic neuritis, surgery is used to decompress the orbital compartment by exposure of the intracanalicular part of the optic nerve.[40]
  • Modern craniomaxillofacial surgery requires detailed consideration of the diagnosis and treatment of traumatic visual pathway damage with the ultimate goal of preserving visual acuity.[40]

Prevention

There are no established measures for the primary prevention of optic neuritis.

References

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