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Introduction. Optic neuritis Atypical optic neuritisTreatment of optic neuritisOptic neuritis and MS. Optic Neuritis: Epidemiology. Incidence: 1-5 per 100 000 per yearHighest incidence in CaucasiansCountries with high latitudes: genetics?SpringtimeAges 20-49Women. Optic Neuritis. Sub-acut
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1. Updates on Optic Neuritis Briar Sexton
Neuro-ophthalmology Clinical Day
Friday, November 18, 2005
2. Introduction Optic neuritis
Atypical optic neuritis
Treatment of optic neuritis
Optic neuritis and MS
3. Optic Neuritis: Epidemiology Incidence: 1-5 per 100 000 per year
Highest incidence in
Caucasians
Countries with high latitudes: genetics?
Springtime
Ages 20-49
Women
4. Optic Neuritis Sub-acute, monocular visual loss
Painful extraocular movements
RAPD
Dyschromatopsia
Decreased contrast
sensitivity
VF deficits
5. Fundus Signs of Optic Neuritis
6. InvestigationsBased on ONTT results for typical optic neuritis Demyelination is the most common cause
No need for laboratory investigation
i.e. ESR, ANA
Need to do MRI of the brain
Assess MS risk
7. Atypical Optic Neuritis Atypical symptoms
Unusual tempo of onset
Absence of pain
Co-morbidity
Atypical signs
Progressive decline in vision > 2/52
Severe/hemorrhagic disc edema
Uveitis: vitritis, retinitis, choroiditis
Persistent ON sheath enhancement on MRI
8. Fundus Photos: Atypical ON
9. Corticosteroid Dependent Optic Neuritis Another atypical optic neuritis
Response to steroids
Vision falls with taper
Requires investigation
10. Atypical Optic Neuritis: Work-up Laboratory investigations
CBC, ESR, ANA, MHA-ATP, ACE
Lyme, Baronella, TB skin test
CXR
Consider LP
Make sure MRI images optic nerve/orbits
11. Visual Fields Central scotomas
Paracentral scotomas
Altitudinal defects
12. Neuroimaging MRI
FLAIR sequencing
Gadolinium enhancement
Optic nerve sheath enhancement with gad
Periventricular white matter lesions on FLAIR
13. MRI: Nerve Sheath Enhancement
14. MRI: White Matter Lesions
15. The Optic Neuritis Treatment Trial (ONTT) Objective: to evaluate the role of corticosteroids in the treatment of unilateral optic neuritis
Inclusion criteria: unilateral optic neuritis
16. The ONTT: Methods Randomization to one of 3 groups
IV steroids: 250 mg methylprednisolone qid x 3 days, oral prednisone (1mg/kg) x 11 days
Oral steroids: prednisone 1mg/kg/day x 14 days
Oral placebo: 14 days
17. ONTT: Results IV steroids
More rapid recovery but same endpoint
Protective v. placebo at 2 years, not 3
Oral prednisone
Higher rate of new ON attacks at 1 year
Highest rate of relapse at 5 years
18. The ONTT and Oral Prednisone Routing vs. Dose?
Probably dose: Greater CD4 than CD8 effect
19. Prognosis Natural history: worsening over days to weeks followed by spontaneous recovery
79% of patients begin to recover by 3/52
93% of patients show improvement by 5/52
Ongoing clinical improvement to 1 year
VEP latency improves to 2 years
20. Prognosis Severity of initial visual loss is related to final visual outcome
Most recover well
74% = 20/20
92% = 20/40
21. Visual Sequelae Optic nerve head pallor will develop
VF deficits may persist
Uhtoffs phenomenon
Pulfrich phenomenon
22. Optic Neuritis RecurrenceFrom the ONTT 35% of patients experienced recurrence in the previously affected eye or an attack in the fellow eye at 10 years
Recurrence rate was double in those with CDMS
Recurrence rate highest in the oral steroid group
23. Sub-clinical Optic Neuritis Not all optic neuritis attacks are clinically evident
Sisto et al 2005
VEP abnormalities in 54.4% of CD-MS patients asymptomatic for visual impairment
Vidovic et al 2005
70% of visually asymptomatic MS patients had GVF defects consistent with optic neuritis
24. Optic Neuritis and MS Clinical diagnosis
2 demyelinating attacks separated in time and space
Sequential optic neuritis in one eye than the other meets the criteria
Discrete attacks in the same eye meets the criteria
Radiologic: Mac Donald Criteria
25. Optic Neuritis and MS Lessell et al. 1988: 58% of optic neuritis at 15 years in initially isolated cases
38-50% of all CDMS develops optic neuritis at some point
26. Radiologic Predictors of MS10 year ONTT data White matter lesions on MRI
Risk is 22% if no baseline brain lesions
Risk is 56% if = 1 baseline lesion
Risk increases with increasing lesions
27. Clinical Predictors of MSONTT 10 year data Low risk if no MRI lesions and
Male gender
Optic disc swelling
No CDMS in subset with above and one of
No pain
Severe disc edema
Peripapillary hemorrhages
Retinal exudates
28. Managing Optic Neuritis and MS Positive MRI
Consider immunomodulatory therapy ie interferon or glatiramer acetate
Patients should be seen by neurology
29. CHAMPS Study Effect of Interferon B 1a treatment in patients with optic neuritis and MRI changes compatible with MS
Significantly less CDMS
Less progression of MRI lesions
30. Conclusions Patients must be investigated for demyelination
Remember the atypical optic neuritis