Optic Neuritis

OPTIC NEURITIS:
• Optic neuritis includes inflammatory & demyelinating disorders of Optic Nerve.
Aetiology: - {mne:
1. Demyelinating Disorders – most common cause of Optic neuritis
o Multiple sclerosis
o Neuromyelitis optica (Devic’s disease), Diffuse periaxial encephalitis of Schilder
o About 70% of established multiple sclerosis may develop optic neuritis
2. Idiopathic
3. Hereditary Optic neuritis: - Leber’s disease
4. Parainfectious Optic Neuritis: - associated with viral infections
o Measles, Mumps, Chickenpox, Whooping Cough, Glandular fever
o May also occur following immunization
5. Infectious Optic Neuritis:
o Sinus related – with acute ethmoiditis
o Associated with Cat scratch fever, Syphilis (during primary or secondary stage),
Tuberculosis, Lyme disease, Cryptococcal meningitis in patients with AIDS.
6. Autoimmune disorders:
o Sarcoidosis, Systemic Lupus Erythematosus, Polyarteritis nodosa, Guillain-
Barre Syndrome, Wegener’s granulomatosis
7. Toxic Optic Neuritis – Toxic amblyopia
o Common causes are: - Quinine, Spurious/Methyl Alcohol, Ethambutol
Anatomical Types: - 3 types:

1. Papillitis:
 Refers to involvement of Optic Disc in inflammatory and demyelinating
disorders.
 Usually unilateral (sometimes bilateral)
2. Neuroretinitis:
 Refers to combined involvement of optic disc & surrounding retina in the
macular area
3. Retrobulbar Neuritis:
 Characterized by involvement of Optic Nerve behind the eyeball
 Clinical features of acute retrobulbar neuritis are similar to acute papillitis
except for certain fundus changes & ocular changes described below.
Typical vs Atypical Optic Neuritis:
• Typical Optic Neuritis – associated with Demyelinating disorders, particularly
Multiple Sclerosis.
• Atypical Optic Neuritis – associated with causes other than Demyelinating
disorders
Clinical Features:
Symptoms:
• May be asymptomatic
• Visual Loss – Monocular, sudden, progressive & profound visual loss (hallmark)
• Delayed Dark Adaptation
• Visual obscuration in bright light
• Impairment of colour vision
• Phosphenes: Movement Phosphenes & Sound-Induced Phosphenes
o (Phosphenes refers to glowing sensations produced by non-photic/inadequate stimuli)
• UHTHOFF’S SYMPTOM:
o Episodic transient obscuration of vision on exertion and on exposer to
heat, which recovers on resting or moving away from heat.
• PULFRICH’S PHENOMENON:
o Impaired Depth Perception, particularly that of moving object
• Pain:
o Mild dull Eyeache – more marked in Retrobulbar Neuritis
o Aggravated by ocular movements (esp., in upward/downward directions due to
attachment of some fibres of superior rectus to the dura mater)
Signs:
• Markedly reduced Visual acuity
• Severely impaired Coloured vision (typically Red Desaturation)
• Pupil:
o Marcus-Gunn Pupil – indicates Relative Afferent Pupillary Defect (RAPD)
 Detected by Swinging Flash Light Test
 Pupil shows ill-sustained constriction to light
• Ophthalmoscopic Features:
o Papillitis
 Hyperaemia of disc
 Blurring of margins
 Disc becomes oedematous  physiological cup is obliterated (in
papillitis Disc Oedema rarely exceeds 2-3 D, while in papilloedema it becomes 3-6 D)
 Congested & tortuous Retinal Vessels
 Splinter Haemorrhages & Fine Exudates may be see
o Slit-lamp Examination:
 Reveals inflammatory cells in the vitreous
 Neuroretinitis: - Inflammatory signs may also be present in the
surrounding retina when Papillitis is associated with macular star
formation (the condition is known as neuroretinitis).
o Retrobulbar neuritis:
 Fundus appears normal
 Condition is typically defined as a disease where neither the
Ophthalmologist nor the patient sees anything – temporal pallor of
disc may be seen
• Visual Field Changes:
o Most common field defect – relative central or Centrocaecal Scotoma
o Other field defect (rarely) – Paracentral Nerve Fibre Bundle Defect
• Impaired Contrast Sensitivity
• Visually Evoked Response (VER) – shows:
o Reduced amplitude
o Delay in transmission time
• Fundus fluorescein angiography: - reveals mild to moderate leak in early phases
 which increases with time
Differential Diagnosis:
• Papillitis should be differentiated from
o Papilloedema
o Pseudopapillitis
o Ischaemic Optic Neuropathy
o Anterior Orbital Compressive Neuropathy
• Acute Retrobulbar Neuritis must be differentiated from
o Malingering
o Hysterical blindness
o Cortical blindness
o Indirect Optic Neuropathy
Evolution, Recovery & Complications:

• Evolution:
o Typically, the visual acuity & colour vision is lost progressively over 2-5 days
• Recovery:
o Rate of visual recovery is slower than rate of visual loss
o Usually starts within 2 weeks  takes 4-6 weeks
o About 75-90% have good visual recovery
• Complications:
o Recurrent attacks of Acute Retrobulbar neuritis  followed by Primary
Optic Atrophy
o Recurrent attacks of Papillitis  followed by Postneuritic Optic Atrophy 
leading to Complete Blindness
Treatment:
• Treatment of causes:
o Although little can be done for Idiopathic & Hereditary Optic Neuritis and that associated with
Demyelinating disorders
o Methyl Alcohol, Quinine, Ethambutol intake must be stopped
• Corticosteroid Therapy: - may shorten the period of visual loss
o Oral PREDNISOLONE therapy alone is contraindicated
o Intravenous METHYLPREDNISOLONE/DEXAMETHASONE
 If brain shows lesions supportive of Multiple sclerosis  each patient
should receive immediate intravenous METHYLPREDNISOLONE 
Followed by Oral PREDNISOLONE  Tapered over time – this therapy
will delay conversion to clinical MS over the next 2 years
 Indications for intravenous METHYLPREDNISOLONE in acute Optic
neuritis patients with a normal brain MRI scan:
 Visual loss in both eyes simultaneously or subsequently
within hours or days of each other
 When the only good eye is affected
 When the slow progressive visual loss continues to occur
• Interferon therapy:
o Reported to reduce recurrences in patients with multiple sclerosis
Differentiating Features of Papilloedema, Papillitis & Pseudopapillitis:
FEATURE PAPILLOEDEMA PAPILLITIS PSEUDOPAPILLITIS

Aetiology Disc Oedema + raised Inflammatory &
Intracranial Pressure Demyelinating disorders
Laterality Usually bilateral Usually unilateral Unilateral/Bilateral
Symptoms:
• Visual Acuity Transient attacks of Marked loss of vision of Defective vision
blurred vision sudden onset depending upon the
Later vision decreases degree of refractive error
due to Optic atrophy
• Pain & Tenderness Absent May be present with Absent
Ocular movements
Fundus Examination:
• Media Clear Posterior Vitreous Haze Clear
is common
• Disc-Colour Red & Juicy Marked Hyperaemia Reddish
appearance
• Disc-Margins Blurred Blurred Not well defined
• Disc-Swelling 2-6 Dioptres Usually not more than 3 Depends on the degree of
Dioptres Hypermetropia
• Peripapillary Oedema Present Present Absent
• Venous Engorgement More marked Less marked Absent
• Retinal Haemorrhages Marked Usually not present Not present
• Retinal Exudates More marked Less marked Absent
• Macula Macular star may be Macular fan may be Absent
present present
Fields Enlarged Blind Spot Central Scotoma (more No defect
for colours)
Fluorescein Vertical oval pool of Minimal leakage of dye No leakage of dye
Angiography: dye due to leakage

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OPTIC NEURITIS:

• Optic neuritis includes inflammatory & demyelinating disorders of Optic Nerve.

Anatomical Types: - 3 types:

Evolution, Recovery & Complications:

Differentiating Features of Papilloedema, Papillitis & Pseudopapillitis:

FEATURE PAPILLOEDEMA PAPILLITIS PSEUDOPAPILLITIS

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