Optic neuritis - Clinicals, Diagnosis, and Management

Opthalmology

Clinicals - History

Fact Explanation
Introduction This is an inflammatory condition of the optic nerve causing swelling and demyelination. This condition affects the vision of the patient. This can be either unilateral(common in adults) or bilateral(common in children). Though the condition is reversible there can be a residual impairment of the vision. Optic neuritis can be present as an isolated case or associated with multiple sclerosis( common presentation). Annual incidence is around 4-5: 100 000 while prevelence is around 115:100 000. Introduction
This is an inflammatory condition of the optic nerve causing swelling and demyelination. This condition affects the vision of the patient. This can be either unilateral(common in adults) or bilateral(common in children). Though the condition is reversible there can be a residual impairment of the vision. Optic neuritis can be present as an isolated case or associated with multiple sclerosis( common presentation). Annual incidence is around 4-5: 100 000 while prevelence is around 115:100 000.
Age of the patient As described in the introduction acute onset of the optic neuritis is more common in between 25-45 age group. Age of the patient
As described in the introduction acute onset of the optic neuritis is more common in between 25-45 age group.
Sex Females(2:1) are known to more affect than males. Sex
Females(2:1) are known to more affect than males.
Sudden onset reduction of vision This visual impairment is sudden onset(over few hours) and commonly affect one eye. Patient will loose vision rapidly and it can be partial or complete visual loss. This impairment will be peak in one to two weeks. Research has shown that the visual impairment can be induce with exposure to heat or following exercise. This condition calls Uhthoff phenomenon.
Visual quality also can affected as described in
Pulfrich phenomenon( when an object passes in a straight line patient see it as going in a elliptical/ curved line). This is due a conduction problem of optic nerve.
Sudden onset reduction of vision
This visual impairment is sudden onset(over few hours) and commonly affect one eye. Patient will loose vision rapidly and it can be partial or complete visual loss. This impairment will be peak in one to two weeks. Research has shown that the visual impairment can be induce with exposure to heat or following exercise. This condition calls Uhthoff phenomenon.
Visual quality also can affected as described in
Pulfrich phenomenon( when an object passes in a straight line patient see it as going in a elliptical/ curved line). This is due a conduction problem of optic nerve.
Reduce the quality of vision Patient will loose the colour perception. This condition calls dyschromatopsia. This loosing colour vision commonly affect red colour. Impairment will be more prominent in unilateral involvement as the patient can compare the affected eye with normal one.
Patients will complain seen of flash lights during eye movements.
Reduce the quality of vision
Patient will loose the colour perception. This condition calls dyschromatopsia. This loosing colour vision commonly affect red colour. Impairment will be more prominent in unilateral involvement as the patient can compare the affected eye with normal one.
Patients will complain seen of flash lights during eye movements.
Reduced sensation about the brightness of light Patient will have reduced sensation about the brightness of light, as there are some changes occur in reacting of pupils( affects afferent nerves of pupils) to the light following this inflammatory condition. Reduced sensation about the brightness of light
Patient will have reduced sensation about the brightness of light, as there are some changes occur in reacting of pupils( affects afferent nerves of pupils) to the light following this inflammatory condition.
Pain during moving eyes This is a common presentation in more than 90% of adult patients and not much common among paediatric poppulation. There will be a retro orbital pain in affected eye during moving the eye ball. This can be due to the swelling following inflammation. In some patients this is appear secondary to visual impairment. Pain during moving eyes
This is a common presentation in more than 90% of adult patients and not much common among paediatric poppulation. There will be a retro orbital pain in affected eye during moving the eye ball. This can be due to the swelling following inflammation. In some patients this is appear secondary to visual impairment.
Headache This is a common presentation in children, possibly associated with visual problems. Headache
This is a common presentation in children, possibly associated with visual problems.
History of recurrent similer attacks/ associated symptoms suggestive of multiple sclerosis or family history of multiple sclerosis. In optic neuritis occur with multiple sclerosis will present as recurrent attacks. Previous episodes can affect same eye or the other one. Those episodes also may associated with other symptoms of multiple sclerosis.
Patient may have symptoms suggestive of multiple sclerosis like sensory impairment, muscles weakness, bladder/ bowel dysfunction and unbalanced gait. Around 50% of patients with multiple sclerosis will develop optic neuritis. Patient with positive history of multiple sclerosis is at risk of developing it.
History of recurrent similer attacks/ associated symptoms suggestive of multiple sclerosis or family history of multiple sclerosis.
In optic neuritis occur with multiple sclerosis will present as recurrent attacks. Previous episodes can affect same eye or the other one. Those episodes also may associated with other symptoms of multiple sclerosis.
Patient may have symptoms suggestive of multiple sclerosis like sensory impairment, muscles weakness, bladder/ bowel dysfunction and unbalanced gait. Around 50% of patients with multiple sclerosis will develop optic neuritis. Patient with positive history of multiple sclerosis is at risk of developing it.
Recent history suggestive of respiratory tract infection Optic neuritis can occur following respiratory tract infections, commonly with common organisms causing pneumonia. So patient may give a recent past history of productive cough, pleuritic type chest pain, wheezing and haemoptysis. Recent history suggestive of respiratory tract infection
Optic neuritis can occur following respiratory tract infections, commonly with common organisms causing pneumonia. So patient may give a recent past history of productive cough, pleuritic type chest pain, wheezing and haemoptysis.
Recent history of viral infections like encephalitis, measles, rubella, chickenpox, herpes zoster, mumps, and mononucleosis. Patient with these infections are also at risk of developing optic neuritis. Recent history of viral infections like encephalitis, measles, rubella, chickenpox, herpes zoster, mumps, and mononucleosis.
Patient with these infections are also at risk of developing optic neuritis.
Recent bacterial infections like tuberculosis, syphilis and meningitis These patients are also at risk of developing optic neuritis. Recent bacterial infections like tuberculosis, syphilis and meningitis
These patients are also at risk of developing optic neuritis.
History of recent fungal infections Fungai infections with Cryptococcus neoformans also leads to development of potic neuritis. This causes commonly respiratory tract infections and common in people with suppressed immunity(eg; AIDS patients, patients receiving immunosuppressive drugs). History of recent fungal infections
Fungai infections with Cryptococcus neoformans also leads to development of potic neuritis. This causes commonly respiratory tract infections and common in people with suppressed immunity(eg; AIDS patients, patients receiving immunosuppressive drugs).
History of autoimmune diseases like systemic lupus erythematosus and sarcoidosis. Autoimmune diseases are also contribute to the development of this condition. In systemic lupus erythematosus patients will develop joint pain and swelling, skin rashes and oral ulcers. In sarcoidosis patient can present with respiratory symptoms like difficulty in breathing, cough, chest pain due to grannuloma formation in lungs. This can affect various organs and tissues. History of autoimmune diseases like systemic lupus erythematosus and sarcoidosis.
Autoimmune diseases are also contribute to the development of this condition. In systemic lupus erythematosus patients will develop joint pain and swelling, skin rashes and oral ulcers. In sarcoidosis patient can present with respiratory symptoms like difficulty in breathing, cough, chest pain due to grannuloma formation in lungs. This can affect various organs and tissues.
Drug history Some drugs like ethambutol, Amiodarone, isoniazid can cause optic neuritis. Drug history
Some drugs like ethambutol, Amiodarone, isoniazid can cause optic neuritis.
Immunization history Post vaccination optic neuritis is known to occur following some vaccines like hepatitis B, influenza and measles. Immunization history
Post vaccination optic neuritis is known to occur following some vaccines like hepatitis B, influenza and measles.
Dietary history Vitamin B12 deficiency can leads to optic neuritis. animal products commonly contains vitamin B12 like eggs, milk, cheese, other milk products, meat and fish. So vegitarians are at risk of vitamin B12 deficiency. Dietary history
Vitamin B12 deficiency can leads to optic neuritis. animal products commonly contains vitamin B12 like eggs, milk, cheese, other milk products, meat and fish. So vegitarians are at risk of vitamin B12 deficiency.
Social history of alcohol in take and cigarette smoking Alcohol intake and cigarette smoking also causes optic neuritis. Social history of alcohol in take and cigarette smoking
Alcohol intake and cigarette smoking also causes optic neuritis.
History of trauma to head or local trauma to eyes Trauma can induce optic neuropathy causing visual impairments. History of trauma to head or local trauma to eyes
Trauma can induce optic neuropathy causing visual impairments.

Clinicals - Examination

Fact Explanation
Inspection of the eyes Inspection will be usually normal. There wont be ptosis, eye ball deviation, squints or retro orbital inflammatory changes.
Patient will complain pain and seen of flash lights during eye movements.
Inspection of the eyes
Inspection will be usually normal. There wont be ptosis, eye ball deviation, squints or retro orbital inflammatory changes.
Patient will complain pain and seen of flash lights during eye movements.
Visual aquity Visual acqity can measure with Snellen's chart and it will be reduced in various degrees from mild impairment to total loss of vision. But all patients will have some degree of visual impairment. Either it can be unilateral or bilateral. Visual aquity
Visual acqity can measure with Snellen's chart and it will be reduced in various degrees from mild impairment to total loss of vision. But all patients will have some degree of visual impairment. Either it can be unilateral or bilateral.
Visual fields The most common visual field defect is central scotomas while all types of visual field defects can occur like diffuse vision loss and hemianopia. Visual fields
The most common visual field defect is central scotomas while all types of visual field defects can occur like diffuse vision loss and hemianopia.
Colour vision This is a more specific examination finding in optic neuritis. Mostly cause red colour blindness and patient will see red objects as pink or orange. Can use Ishihara color charts for assessment.
Changes in perception of brightness can assess using Pelli-Robson chart. As response to light brightness will be changed with the disease.
Colour vision
This is a more specific examination finding in optic neuritis. Mostly cause red colour blindness and patient will see red objects as pink or orange. Can use Ishihara color charts for assessment.
Changes in perception of brightness can assess using Pelli-Robson chart. As response to light brightness will be changed with the disease.
Accommodation and light reflex Three will be an accommodation and light reflex impairment with this due to poor pupillary reaction. Accommodation and light reflex
Three will be an accommodation and light reflex impairment with this due to poor pupillary reaction.
fundoscopic examination Majority of patients fundoscopic examination will be normal. Among others diffuse disk oedema with blurring of disk margins is the most common finding. Disk atrophy can be seen in some patients with recurrent episodes. fundoscopic examination
Majority of patients fundoscopic examination will be normal. Among others diffuse disk oedema with blurring of disk margins is the most common finding. Disk atrophy can be seen in some patients with recurrent episodes.
Central nervous system examination This will reveal presence of any neurological deficit suggestive of multiple sclerosis. localized muscle weakness, patchy sensory impairment, hyper reflexia, clonus, increased muscle tone can be identified with visual impairment. Central nervous system examination
This will reveal presence of any neurological deficit suggestive of multiple sclerosis. localized muscle weakness, patchy sensory impairment, hyper reflexia, clonus, increased muscle tone can be identified with visual impairment.
Features of nutritional deficiency like pallor, angular stomatitis and chelitis As vitamin B12 deficiency can lead to optic neuritis these signs in general examination will be useful. Features of nutritional deficiency like pallor, angular stomatitis and chelitis
As vitamin B12 deficiency can lead to optic neuritis these signs in general examination will be useful.
Respiratory system examination This is important in identifying any primary infection9 viral, bacterial or fungal) in lung, causing optic neuritis development. Respiratory system examination
This is important in identifying any primary infection9 viral, bacterial or fungal) in lung, causing optic neuritis development.
Any rashes in body, arthritis, oral ulcers and alopacia This will important in assessing any co existing autoimmune connective tissue disorder like systemic lupus erythematosus. Any rashes in body, arthritis, oral ulcers and alopacia
This will important in assessing any co existing autoimmune connective tissue disorder like systemic lupus erythematosus.
Skin rash with fever and ill health Some viral infections like rubella, mesela and herpes zoster which appear as a rash also can leads to this condition. Skin rash with fever and ill health
Some viral infections like rubella, mesela and herpes zoster which appear as a rash also can leads to this condition.
Photophobia, neck stiffness, fever These findings can be seen in meningitis. Meningitis is another cause of development of optic neuritis among paediatric population. Photophobia, neck stiffness, fever
These findings can be seen in meningitis. Meningitis is another cause of development of optic neuritis among paediatric population.

Investigations - Diagnosis

Fact Explanation
Visual Evoked Potential (VEP) This assess the electrical response in optic nerve to a various visual physiological stimuli. this can confirm that nerve conduction of the optic nerve is affected from this disease condition. In optic neuritis, wave form of this study is typically delayed. Visual Evoked Potential (VEP)
This assess the electrical response in optic nerve to a various visual physiological stimuli. this can confirm that nerve conduction of the optic nerve is affected from this disease condition. In optic neuritis, wave form of this study is typically delayed.
MRI brain and spinal cord MRI brain useful in assessing the ongoing inflammatory condition of the optic nerve. This is a highly specific and sensitive test in diagnosing these soft tissue changes.
Also MRI brain and spinal cord(with gadolinium enhancement) useful in diagnosing associated multiple sclerosis( demyelination of the central nervous system) with this presentation.
MRI brain and spinal cord
MRI brain useful in assessing the ongoing inflammatory condition of the optic nerve. This is a highly specific and sensitive test in diagnosing these soft tissue changes.
Also MRI brain and spinal cord(with gadolinium enhancement) useful in diagnosing associated multiple sclerosis( demyelination of the central nervous system) with this presentation.
ESR, CRP These test will useful in assessing the ongoing inflammatory condition of the body. ESR, CRP
These test will useful in assessing the ongoing inflammatory condition of the body.
Full blood count Low haemoglobin level will give a rough idea about the patients nutritional level if the patient is pale. WBC count will be high in an inflammatory condition. Full blood count
Low haemoglobin level will give a rough idea about the patients nutritional level if the patient is pale. WBC count will be high in an inflammatory condition.
Vitamin B12 level This will be useful in clinically suspected symptomatic patient with vitamin B12 deficiency. Vitamin B12 level
This will be useful in clinically suspected symptomatic patient with vitamin B12 deficiency.
ANA and DS DNA If patient is suspected to have autoimmune condition like systemic lupus erythematosis these test will be helpful. ANA and DS DNA
If patient is suspected to have autoimmune condition like systemic lupus erythematosis these test will be helpful.
neuromyelitis optica antibody This is useful in excluding neuromyelitis optica which has a similer presentation. neuromyelitis optica antibody
This is useful in excluding neuromyelitis optica which has a similer presentation.
CSF studies If the patient is suspected to have meningitis CSF studies will useful. Also findings will support the diagnosis of multiple sclerosis in suspected case (oligoclonal band, normal/ mildly raised protein and lymphocytes). CSF studies
If the patient is suspected to have meningitis CSF studies will useful. Also findings will support the diagnosis of multiple sclerosis in suspected case (oligoclonal band, normal/ mildly raised protein and lymphocytes).
Chest X ray If the patient is suspected to have any respiratory tract infection like pneumonia, tuberculosis chest X is important. Chest X ray
If the patient is suspected to have any respiratory tract infection like pneumonia, tuberculosis chest X is important.
Thyroid function test( third grneration TSH and T4) Thyroid disease can lead to optic neuropathy. Thyroid function test( third grneration TSH and T4)
Thyroid disease can lead to optic neuropathy.
Fasting blood sugar and HbA1c As diabetes mellitus like systemic conditions can cause toxic optic neuropathy this test is useful. Fasting blood sugar and HbA1c
As diabetes mellitus like systemic conditions can cause toxic optic neuropathy this test is useful.
Renal function tests like serum creatinine, blood urea, serum electrolytes chronic kidney disease also causes optic neuropathy. Renal function tests like serum creatinine, blood urea, serum electrolytes
chronic kidney disease also causes optic neuropathy.

Investigations - Management

Fact Explanation
MRI This is useful in assessing the complications during follow up as patient can go into optic atrophy causing permanent visual defects.
If the patient developed optic neuritis secondary to multiple sclerosis this test again useful in assessing the progression of the illness.
MRI
This is useful in assessing the complications during follow up as patient can go into optic atrophy causing permanent visual defects.
If the patient developed optic neuritis secondary to multiple sclerosis this test again useful in assessing the progression of the illness.
Visual Evoked Potentials In optic neuritis there is a slowness in waveform and this slowness will remain even after complete recovery of the disease. So this test will be useful in follow up as it can diagnose the condition even after recovery of clinical symptoms. Visual Evoked Potentials
In optic neuritis there is a slowness in waveform and this slowness will remain even after complete recovery of the disease. So this test will be useful in follow up as it can diagnose the condition even after recovery of clinical symptoms.
Chest X ray If the patients primary condition diagnosed as any respiratory tract infection like pneumonia or tuberculosis this will be useful in assessing the patients condition/ improvement with the time. Chest X ray
If the patients primary condition diagnosed as any respiratory tract infection like pneumonia or tuberculosis this will be useful in assessing the patients condition/ improvement with the time.
Full blood count and vitamin B12 levels These tests are useful in follow up if the optic neuritis occur secondary to vitamin B12 deficiency. These tests will give an idea about the patients improvement following treatments. Full blood count and vitamin B12 levels
These tests are useful in follow up if the optic neuritis occur secondary to vitamin B12 deficiency. These tests will give an idea about the patients improvement following treatments.
ESR, CRP These basic blood investigations give an idea about the current inflammatory condition. ESR, CRP
These basic blood investigations give an idea about the current inflammatory condition.
FBC This also important in assessing the patients current condition of haemoglobin level. FBC
This also important in assessing the patients current condition of haemoglobin level.
MRI If the patient is having multiple sclerosis MRI gives as idea about the patients current disease condition as how far the patients central nervous system affected. MRI
If the patient is having multiple sclerosis MRI gives as idea about the patients current disease condition as how far the patients central nervous system affected.

Management - Supportive

Fact Explanation
Health education Patient should be educated regarding the disease, primary cause for the disease if identified, symptoms associated with, possible complications, investigations needed, available treatment options and prognosis. Health education
Patient should be educated regarding the disease, primary cause for the disease if identified, symptoms associated with, possible complications, investigations needed, available treatment options and prognosis.
Monitoring the patients condition until recovery As in majority of cases this condition is a reversible one monitoring the patients condition can be done until recovery as an out patient. Frequency and number of visits will be change depending on the severity of the disease , primary cause and recovering speed. Monitoring the patients condition until recovery
As in majority of cases this condition is a reversible one monitoring the patients condition can be done until recovery as an out patient. Frequency and number of visits will be change depending on the severity of the disease , primary cause and recovering speed.
Support for daily works As the patients are suffering from a vision problem, they will not able to handle their daily activities as usual. So the support of the family members, friend, relatives will be needed for the patient until recovery. Support for daily works
As the patients are suffering from a vision problem, they will not able to handle their daily activities as usual. So the support of the family members, friend, relatives will be needed for the patient until recovery.
Multidisciplinary team management for rehabilitation in multiple sclerosis Neurologist, ophthalmologist, physiotherapist, psychiatrist, social worker will mainly involve in management and to improve the patient's quality of life. Multidisciplinary team management for rehabilitation in multiple sclerosis
Neurologist, ophthalmologist, physiotherapist, psychiatrist, social worker will mainly involve in management and to improve the patient's quality of life.
Improve nutritional level of the patient Patients nutritional level need to be improved. Patient/ family should be educated regarding essential nutritious components and nutritional sources. So balanced diet containing both macro and micro nutrients in recommended amounts need to be taken. Improve nutritional level of the patient
Patients nutritional level need to be improved. Patient/ family should be educated regarding essential nutritious components and nutritional sources. So balanced diet containing both macro and micro nutrients in recommended amounts need to be taken.
Reduced amount of alcohol intake and stop smoking As toxins like alcohol and tobacco can predispose to optic neuritis patients should be advised to reduce intake of alcohol to a non toxic level and to quit smoking cigarettes. Reduced amount of alcohol intake and stop smoking
As toxins like alcohol and tobacco can predispose to optic neuritis patients should be advised to reduce intake of alcohol to a non toxic level and to quit smoking cigarettes.
Modifying predisposing factors If the patient is on any drug which can leads to optic neuritis, the drug should be stopped/ change to an alternative drug. Need to be avoid the use of those drugs in future. In here patient education is very important. Modifying predisposing factors
If the patient is on any drug which can leads to optic neuritis, the drug should be stopped/ change to an alternative drug. Need to be avoid the use of those drugs in future. In here patient education is very important.

Management - Specific

Fact Explanation
watchful waiting The prognosis of optic neuritis is very good. Majority of patients will recover irrespective of treatments. watchful waiting
The prognosis of optic neuritis is very good. Majority of patients will recover irrespective of treatments.
steroids and ACTH IV steroid ( methylprednisolone) for 3 days followed by tapering dose of oral prednisolone is being used in acute optic neuritis. This treatment will quicken the recovery but not affect the final outcome. Oral prednisolone alone is not recommended.
In multiple sclerosis ACTH also used as it induces the production of endogenous steroids.
During steroid treatment patient should be closely monitor for steroid induced side effects.
steroids and ACTH
IV steroid ( methylprednisolone) for 3 days followed by tapering dose of oral prednisolone is being used in acute optic neuritis. This treatment will quicken the recovery but not affect the final outcome. Oral prednisolone alone is not recommended.
In multiple sclerosis ACTH also used as it induces the production of endogenous steroids.
During steroid treatment patient should be closely monitor for steroid induced side effects.
Plasma exchange This is also use in optic neuritis associated with multiple sclerosis as there is an antibody mediated pathopysiology. Plasma exchange use to remove/ reduce the quantity of these antibodies to reduce progression of disease. This is not effective as steroids, so it remains as the second choice in steroid resistant cases. Plasma exchange
This is also use in optic neuritis associated with multiple sclerosis as there is an antibody mediated pathopysiology. Plasma exchange use to remove/ reduce the quantity of these antibodies to reduce progression of disease. This is not effective as steroids, so it remains as the second choice in steroid resistant cases.
IV immunoglobulin There are no good evidence that these are benefited in optic neuritis but use in following unresponsive steroid therapy or in the presence of contraindications for steroid use. IV immunoglobulin
There are no good evidence that these are benefited in optic neuritis but use in following unresponsive steroid therapy or in the presence of contraindications for steroid use.
immunomodulators like interferon beta-1a, interferon beta-1b and glatiramer acetate These immunomodulators are used in patients with optic neuritis who are not having other symptoms of multiple sclerosis but having brain lesions in MRI. immunomodulators like interferon beta-1a, interferon beta-1b and glatiramer acetate
These immunomodulators are used in patients with optic neuritis who are not having other symptoms of multiple sclerosis but having brain lesions in MRI.
Antibiotics, antiviral treatment or anti fungal treatment these will be useful in the presence of co existing infections. type of antibiotic, rout, dose, duration of treatment will depend on the infection, pathogens and the severity of the disease. Antibiotics, antiviral treatment or anti fungal treatment
these will be useful in the presence of co existing infections. type of antibiotic, rout, dose, duration of treatment will depend on the infection, pathogens and the severity of the disease.

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