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OPTIC NEURITIS

SUBDIVISION NEURO-OPHTHALMOLOGY DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY OF HASANUDDIN

CASE PRESENTATION
Man, age : 30 years, caucasion Main complain : Gradually worsening vision in his left eye, two weeks History : 2 years ago neurologist flashes Head CT was normal Colour blindness Posterior pressure tightness = left eye movement

Vision in left eye worsened when showering Not visual change activities or movements Trauma, redness, discharge or headache : denied Past medical history : (-) Social history : (-) Medications : (-) Drug allergies : (-)

Examination : VOD : 20/20 VOS : 20/30


Ptosis : (-) Resistance to retropulsion Pupil : reactive light : (+), symetrically Defect : left afferent pupillary Hertel : base of 102 mm OD = 19, OS = 18

Extra oculer movement : full OU OS : tight feeling = abduction TIO : 15 Slit lamp : normal FODS : normal (no disc edem) Humphrey visual field : OS = inferior altitudinal defect

Figure 1. Humphrey visual field OD.

Figure 2. Humphrey visual field OS.

One week follow up :


Decreasing vision OS VOD : 20/20 VOS : 20/400 OS : afferent pupillary defect = remained The rest of the exam : same Goldmain visual fields : central scotoma (OS) MRI :
Inflamation of the left optic nerve White matter hyperintensity of the left occipital & right frontal lobes.

Treatment : no corticosteroid (patient choose)

Figure 3.Goldmann Visual Field OS.

Figure 4. MRI demonstrating optic nerve white matter hyperintensity. Figure 5. MRI demonstrating left occipital lobe hyperintensity.

Figure 6. MRI demonstrating right frontal lobe hyperintensity.

One month follow up :


Recovery of VOS Bluring in bright sunlight : (+) No medications VODS : 20/20 No afferent pupillary defect & no tightness on eye movement The rest of the exam : uncharged Humphrey visual field : improvement in the central scotoma.

Clinical manifestation
Triad symptons of optic neuritis :
Loss of vision Dyschromatopsin Eye pain

Initial attact :
Unilateral in 70 % adult patient Bilateral in 30 %

The mean age of onset : the third decade of life (first seventh) Incidence : 1,4 6,4 new cases/100.000 population

Associated visual symptons : reduced perception of light intensity & uhthoffs sympton Visual loss : subtle or proformed Complete loss of vision : single plaque Some cases :
VODS : 20/20 Symptons : - blurred vision on exertion - isolated symptons

Visual loss occur over hours (rarely) & days (most commonly)

Prognosis :
Visual recovery = good Recovery visual acuity : 20-30 or better (65-85%) Most cases : recover visual acuity in a few months Some residual abnormalities :
Abnormalities in contrast sensitivity Color vision Visual field loss Light brightness

High risk : multiple sclerosis In the past = treatment : oral/IV corticosteroid.

OPTIC NEURITIS TREATMENT TRIAL


Multi center study 389 patients acut optic neuritis Three treatment groups :
I. oral prednison (1mg/kg daily) = 14 days II. I.V. methylpredisolone, 250g four times daily = 3 days III. Oral placebo = 14 days

Criteria :
Age range : 18 46 years Acute unilateral optic neuritis + visual symptons 8 days or less Afferent pupillary defect & visual field defect in the affected eye No previous corticosteroid treatment No systemic disease other than M.S. associated with optic neuritis.

Excluded :
Collagen vascular disease Syphilis Sarcoidosis

Result :
Group II : recovery of visual loss = speeds At 6 months : no significant differences in visual acuity Oral predison : increase the risk of recurrent optic neuritis Oral predison : no longer advised Group II : reduced the rate of M.S