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[4][7][8][9].
Age of the patient As described in the introduction acute onset of the optic neuritis is more common in between 25-45 age group[4][9].
Sex Females(2:1) are known to more affect than males[4][9].
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[4][7][9][12]. 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)[1]. 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[10][11].
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[9][13].
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[9][14].
Headache This is a common presentation in children, possibly associated with visual problems[7][15].
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[2][5][6].
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[14][16].
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[15][17][18].
Recent bacterial infections like tuberculosis, syphilis and meningitis These patients are also at risk of developing optic neuritis[9][14][19].
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)[20][21].
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[4][9].
Drug history Some drugs like ethambutol, Amiodarone, isoniazid can cause optic neuritis[3][4].
Immunization history Post vaccination optic neuritis is known to occur following some vaccines like hepatitis B, influenza and measles[22][23].
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[3][4][24].
Social history of alcohol in take and cigarette smoking Alcohol intake and cigarette smoking also causes optic neuritis[3][4].
History of trauma to head or local trauma to eyes Trauma can induce optic neuropathy causing visual impairments[3][4].
References
  1. O'DOHERTY M, FLITCROFT DI. An unusual presentation of optic neuritis and the Pulfrich phenomenon J Neurol Neurosurg Psychiatry [online] 2007 Aug, 78(8):906-907 [viewed 02 October 2014] Available from: doi:10.1136/jnnp.2006.094771
  2. THE OPTIC NEURITIS STUDY GROUP. Multiple Sclerosis Risk after Optic Neuritis: Final Optic Neuritis Treatment Trial Follow-Up Arch Neurol [online] 2008 Jun, 65(6):727-732 [viewed 02 October 2014] Available from: doi:10.1001/archneur.65.6.727
  3. SHARMA P, SHARMA R. Toxic optic neuropathy Indian J Ophthalmol [online] 2011, 59(2):137-141 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77035
  4. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125
  5. GOLDENBERG MM. Multiple Sclerosis Review P T [online] 2012 Mar, 37(3):175-184 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351877
  6. HUTCHINSON WM. Acute optic neuritis and the prognosis for multiple sclerosis. J Neurol Neurosurg Psychiatry [online] 1976 Mar, 39(3):283-289 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC492267
  7. MENON V, SAXENA R, MISRA R, PHULJHELE S. Management of optic neuritis Indian J Ophthalmol [online] 2011, 59(2):117-122 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77020
  8. SAINI M, KHURANA D. Chronic relapsing inflammatory optic neuropathy Ann Indian Acad Neurol [online] 2010, 13(1):61-63 [viewed 03 October 2014] Available from: doi:10.4103/0972-2327.61280
  9. VOSS E, RAAB P, TREBST C, STANGEL M. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis Ther Adv Neurol Disord [online] 2011 Mar, 4(2):123-134 [viewed 03 October 2014] Available from: doi:10.1177/1756285611398702
  10. KATZ B. The dyschromatopsia of optic neuritis: a descriptive analysis of data from the optic neuritis treatment trial. Trans Am Ophthalmol Soc [online] 1995:685-708 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312075
  11. QUIROS PA, TORRES RJ, SALOMAO S, BEREZOVSKY A, CARELLI V, SHERMAN J, SADUN F, DE NEGRI A, BELFORT R, SADUN AA. Colour vision defects in asymptomatic carriers of the Leber's hereditary optic neuropathy (LHON) mtDNA 11778 mutation from a large Brazilian LHON pedigree: a case-control study Br J Ophthalmol [online] 2006 Feb, 90(2):150-153 [viewed 03 October 2014] Available from: doi:10.1136/bjo.2005.074526
  12. PéREZ-CAMBRODí RJ, GóMEZ-HURTADO CUBILLANA A, MERINO-SUáREZ ML, PIñERO-LLORENS DP, LARIA-OCHAITA C. Optic neuritis in pediatric population: A review in current tendencies of diagnosis and management J Optom [online] 2014 Jul, 7(3):125-130 [viewed 03 October 2014] Available from: doi:10.1016/j.optom.2013.12.008
  13. DIGRE KB, BRENNAN KC. Shedding Light on Photophobia J Neuroophthalmol [online] 2012 Mar, 32(1):68-81 [viewed 03 October 2014] Available from: doi:10.1097/WNO.0b013e3182474548
  14. JAAFAR J, HITAM WH, NOOR RA. Bilateral atypical optic neuritis associated with tuberculosis in an immunocompromised patient Asian Pac J Trop Biomed [online] 2012 Jul, 2(7):586-588 [viewed 03 October 2014] Available from: doi:10.1016/S2221-1691(12)60102-6
  15. HASAN S, B. BASRI H, P. HIN L, STANSLAS J. Encephalitis Followed by Optic Neuritis: A Case Report and Review of Literature Pak J Med Sci [online] 2013, 29(3):859-862 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809309
  16. CHIANG WY, HUANG HM. Bilateral monosymptomatic optic neuritis following Mycoplasma pneumoniae infection: A case report and literature review Indian J Ophthalmol [online] 2014 Jun, 62(6):724-727 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.136236
  17. LOVE S. Demyelinating diseases J Clin Pathol [online] 2006 Nov, 59(11):1151-1159 [viewed 03 October 2014] Available from: doi:10.1136/jcp.2005.031195
  18. PISAPIA R, RIANDA A, MARIANO A, TESTA A, GALGANI S, VINCENZI L, ABDEDDAIM A, OLIVA A, NARCISO P. Varicella zoster virus infection presenting as isolated diplopia: a case report BMC Infect Dis [online] :138 [viewed 03 October 2014] Available from: doi:10.1186/1471-2334-13-138
  19. SMITH GT, GOLDMEIER D, MIGDAL C. Neurosyphilis with optic neuritis: an update Postgrad Med J [online] 2006 Jan, 82(963):36-39 [viewed 03 October 2014] Available from: doi:10.1136/pgmj.2004.020875
  20. MOODLEY A, RAE W, BHIGJEE A, CONNOLLY C, DEVPARSAD N, MICHOWICZ A, HARRISON T, LOYSE A. Early Clinical and Subclinical Visual Evoked Potential and Humphrey's Visual Field Defects in Cryptococcal Meningitis PLoS One [online] , 7(12):e52895 [viewed 03 October 2014] Available from: doi:10.1371/journal.pone.0052895
  21. VILLARROEL A, MAGGIULLI TR. Rare Cryptococus gattii infection in an immunocompetent dairy goat following a cesarean section Med Mycol Case Rep [online] , 1(1):91-94 [viewed 03 October 2014] Available from: doi:10.1016/j.mmcr.2012.09.005
  22. MORADIAN S, AHMADIEH H. Early Onset Optic Neuritis Following Measles-Rubella Vaccination J Ophthalmic Vis Res [online] 2008 Apr, 3(2):118-122 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3589229
  23. SUDARSHAN S, HUANG EH, LIM PL, LEO YS, LIM SA. A case of post-vaccination optic neuritis: coincidence or causative? Eye (Lond) [online] 2012 Nov, 26(11):1498 [viewed 03 October 2014] Available from: doi:10.1038/eye.2012.146
  24. FREEMAN AG. Optic neuropathy and chronic cyanide intoxication: a review. J R Soc Med [online] 1988 Feb, 81(2):103-106 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291478

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[1][2][3].
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[1][4][5].
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[4][6].
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[7][8].
Accommodation and light reflex Three will be an accommodation and light reflex impairment with this due to poor pupillary reaction[9][10].
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[11][4][5].
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[12][13][14].
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[4][15][16].
Respiratory system examination This is important in identifying any primary infection9 viral, bacterial or fungal) in lung, causing optic neuritis development[17][18].
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[1][4].
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[19][20].
Photophobia, neck stiffness, fever These findings can be seen in meningitis. Meningitis is another cause of development of optic neuritis among paediatric population[20][4].
References
  1. VOSS E, RAAB P, TREBST C, STANGEL M. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis Ther Adv Neurol Disord [online] 2011 Mar, 4(2):123-134 [viewed 03 October 2014] Available from: doi:10.1177/1756285611398702
  2. QUIROS PA, TORRES RJ, SALOMAO S, BEREZOVSKY A, CARELLI V, SHERMAN J, SADUN F, DE NEGRI A, BELFORT R, SADUN AA. Colour vision defects in asymptomatic carriers of the Leber's hereditary optic neuropathy (LHON) mtDNA 11778 mutation from a large Brazilian LHON pedigree: a case-control study Br J Ophthalmol [online] 2006 Feb, 90(2):150-153 [viewed 03 October 2014] Available from: doi:10.1136/bjo.2005.074526
  3. JAAFAR J, HITAM WH, NOOR RA. Bilateral atypical optic neuritis associated with tuberculosis in an immunocompromised patient Asian Pac J Trop Biomed [online] 2012 Jul, 2(7):586-588 [viewed 03 October 2014] Available from: doi:10.1016/S2221-1691(12)60102-6
  4. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125
  5. MENON V, SAXENA R, MISRA R, PHULJHELE S. Management of optic neuritis Indian J Ophthalmol [online] 2011, 59(2):117-122 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77020
  6. KELTNER JL, JOHNSON CA, CELLO KE, DONTCHEV M, GAL RL, BECK RW, FOR THE OPTIC NEURITIS STUDY GROUP. Visual Field Profile of Optic Neuritis: A Final Follow-up Report From the Optic Neuritis Treatment Trial From Baseline Through 15 Years Arch Ophthalmol [online] 2010 Mar, 128(3):330-337 [viewed 03 October 2014] Available from: doi:10.1001/archophthalmol.2010.16
  7. KATZ B. The dyschromatopsia of optic neuritis: a descriptive analysis of data from the optic neuritis treatment trial. Trans Am Ophthalmol Soc [online] 1995:685-708 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312075
  8. QUIROS PA, TORRES RJ, SALOMAO S, BEREZOVSKY A, CARELLI V, SHERMAN J, SADUN F, DE NEGRI A, BELFORT R, SADUN AA. Colour vision defects in asymptomatic carriers of the Leber's hereditary optic neuropathy (LHON) mtDNA 11778 mutation from a large Brazilian LHON pedigree: a case-control study Br J Ophthalmol [online] 2006 Feb, 90(2):150-153 [viewed 03 October 2014] Available from: doi:10.1136/bjo.2005.074526
  9. BROADWAY DC. How to test for a relative afferent pupillary defect (RAPD) Community Eye Health [online] 2012, 25(79-80):58-59 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3588138
  10. WAKAKURA M, YOKOE J. Evidence for preserved direct pupillary light response in Leber's hereditary optic neuropathy. Br J Ophthalmol [online] 1995 May, 79(5):442-446 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC505132
  11. SHARPE JA, SANDERS MD. Atrophy of myelinated nerve fibres in the retina in optic neuritis. Br J Ophthalmol [online] 1975 Apr, 59(4):229-232 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1042599
  12. THE OPTIC NEURITIS STUDY GROUP. Multiple Sclerosis Risk after Optic Neuritis: Final Optic Neuritis Treatment Trial Follow-Up Arch Neurol [online] 2008 Jun, 65(6):727-732 [viewed 02 October 2014] Available from: doi:10.1001/archneur.65.6.727
  13. GOLDENBERG MM. Multiple Sclerosis Review P T [online] 2012 Mar, 37(3):175-184 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351877
  14. HUTCHINSON WM. Acute optic neuritis and the prognosis for multiple sclerosis. J Neurol Neurosurg Psychiatry [online] 1976 Mar, 39(3):283-289 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC492267
  15. SHARMA P, SHARMA R. Toxic optic neuropathy Indian J Ophthalmol [online] 2011, 59(2):137-141 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77035
  16. FREEMAN AG. Optic neuropathy and chronic cyanide intoxication: a review. J R Soc Med [online] 1988 Feb, 81(2):103-106 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291478
  17. JAAFAR J, HITAM WH, NOOR RA. Bilateral atypical optic neuritis associated with tuberculosis in an immunocompromised patient Asian Pac J Trop Biomed [online] 2012 Jul, 2(7):586-588 [viewed 03 October 2014] Available from: doi:10.1016/S2221-1691(12)60102-6
  18. CHIANG WY, HUANG HM. Bilateral monosymptomatic optic neuritis following Mycoplasma pneumoniae infection: A case report and literature review Indian J Ophthalmol [online] 2014 Jun, 62(6):724-727 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.136236
  19. LOVE S. Demyelinating diseases J Clin Pathol [online] 2006 Nov, 59(11):1151-1159 [viewed 03 October 2014] Available from: doi:10.1136/jcp.2005.031195
  20. PISAPIA R, RIANDA A, MARIANO A, TESTA A, GALGANI S, VINCENZI L, ABDEDDAIM A, OLIVA A, NARCISO P. Varicella zoster virus infection presenting as isolated diplopia: a case report BMC Infect Dis [online] :138 [viewed 03 October 2014] Available from: doi:10.1186/1471-2334-13-138
  21. HASAN S, B. BASRI H, P. HIN L, STANSLAS J. Encephalitis Followed by Optic Neuritis: A Case Report and Review of Literature Pak J Med Sci [online] 2013, 29(3):859-862 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809309

Differential Diagnoses

Fact Explanation
Multiple sclerosis Multiple sclerosis is a condition associated with patchy inflammation and demyelination of neuronal cells of brain and spinal cord causing permenet/ residual symptoms. Patient will have symptoms like sensory impairment, muscles weakness, bladder/ bowel dysfunction and unbalanced gait. Around 50% of patients with multiple sclerosis will develop optic neuritis. In optic neuritis occur with multiple sclerosis will present as recurrent attacks. MRI will confirm the diagnosis[11][12].
Neuromyelitis optica Neuromyelitis optica is an autoimmune condition causing inflammation and demyelination in optic nerve and spinal cord. This will not affect the nerves in brain. This condition either can remain for long time or can present as recurrent episodes. This will also give symptoms of spinal cord damage associated with symptoms of optic neuritis[1][4].
Nutritional optic neuropathies This is a condition causing gradual progressive, bilateral, symmetrical visual impairment. Colour vision, visual acuity and field vision will be affected. This neuropathy usually occur following ingestion of neuro toxic substances like certain drugs, foods, tobacco and following some systemic conditions like thyroid disease, diabetes mellitus and kidney failure[5][6].
Hereditary optic neuropathies This is a mitochondrial disease causing bilateral visual impairment. It affects visual acuity, field vision and colour vision. As this is a hereditary condition this appear in younger age. genetic testing will confirm the disease[2][3].
Retinal artery occlusion Unilateral, painless sudden onset visual impairment is seen in this condition. These patients will have risk factors for thromboembolism( eg hypertension, hyperlipidaemia, diabetes mellitus). severity of visual impairment will be associated with the blocked artery( eg central retinal artery occlusion, branched retinal artery occlusion) and ischemia area of the retina[7][8].
Glaucoma This is the second leading cause for blindness. Following increased intra occular pressure, there will be retinal neuronal damage, This leads to irreversible visual impairment in visual fields. On examination there will be characteristic changes in optic disc[9][10].
References
  1. COLLONGUES N, DE SEZE J. Current and future treatment approaches for neuromyelitis optica Ther Adv Neurol Disord [online] 2011 Mar, 4(2):111-121 [viewed 03 October 2014] Available from: doi:10.1177/1756285611398939
  2. MAN P, TURNBULL D, CHINNERY P. Leber hereditary optic neuropathy J Med Genet [online] 2002 Mar, 39(3):162-169 [viewed 03 October 2014] Available from: doi:10.1136/jmg.39.3.162
  3. HOWELL N, MCCULLOUGH D, BODIS-WOLLNER I. Molecular genetic analysis of a sporadic case of Leber hereditary optic neuropathy. Am J Hum Genet [online] 1992 Feb, 50(2):443-446 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1682448
  4. JACOB A. Neuromyelitis optica - an update: 2007-2009 Ann Indian Acad Neurol [online] 2009, 12(4):231-237 [viewed 03 October 2014] Available from: doi:10.4103/0972-2327.58277
  5. SHARMA P, SHARMA R. Toxic optic neuropathy Indian J Ophthalmol [online] 2011, 59(2):137-141 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77035
  6. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125
  7. RATRA D, DHUPPER M. Retinal arterial occlusions in the young: Systemic associations in Indian population Indian J Ophthalmol [online] 2012, 60(2):95-100 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.94049
  8. CHOPDAR A. Hemicentral retinal artery occlusion in young adults Indian J Ophthalmol [online] 2013 Jul, 61(7):365 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.97559
  9. AGARWAL R, GUPTA SK, AGARWAL P, SAXENA R, AGRAWAL SS. Current concepts in the pathophysiology of glaucoma Indian J Ophthalmol [online] 2009, 57(4):257-266 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.53049
  10. FOSTER PJ, BUHRMANN R, QUIGLEY HA, JOHNSON GJ. The definition and classification of glaucoma in prevalence surveys Br J Ophthalmol [online] 2002 Feb, 86(2):238-242 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1771026
  11. POLMAN CH, REINGOLD SC, BANWELL B, CLANET M, COHEN JA, FILIPPI M, FUJIHARA K, HAVRDOVA E, HUTCHINSON M, KAPPOS L, LUBLIN FD, MONTALBAN X, O'CONNOR P, SANDBERG-WOLLHEIM M, THOMPSON AJ, WAUBANT E, WEINSHENKER B, WOLINSKY JS. Diagnostic criteria for multiple sclerosis: 2010 Revisions to the McDonald criteria Ann Neurol [online] 2011 Feb, 69(2):292-302 [viewed 03 October 2014] Available from: doi:10.1002/ana.22366
  12. GOLDENBERG MM. Multiple Sclerosis Review P T [online] 2012 Mar, 37(3):175-184 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351877

Investigations - for 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[2][3].
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[4][5].
ESR, CRP These test will useful in assessing the ongoing inflammatory condition of the body[6][7].
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[1][5][7].
Vitamin B12 level This will be useful in clinically suspected symptomatic patient with vitamin B12 deficiency[1][8].
ANA and DS DNA If patient is suspected to have autoimmune condition like systemic lupus erythematosis these test will be helpful[7][9][10].
neuromyelitis optica antibody This is useful in excluding neuromyelitis optica which has a similer presentation[11][12].
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)[7][13][14].
Chest X ray If the patient is suspected to have any respiratory tract infection like pneumonia, tuberculosis chest X is important[7][15][16].
Thyroid function test( third grneration TSH and T4) Thyroid disease can lead to optic neuropathy[1][17].
Fasting blood sugar and HbA1c As diabetes mellitus like systemic conditions can cause toxic optic neuropathy this test is useful[1][18][19].
Renal function tests like serum creatinine, blood urea, serum electrolytes chronic kidney disease also causes optic neuropathy[1][7].
References
  1. SHARMA P, SHARMA R. Toxic optic neuropathy Indian J Ophthalmol [online] 2011, 59(2):137-141 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77035
  2. JAYARAMAN M, GANDHI RA, RAVI P, SEN P. Multifocal visual evoked potential in optic neuritis, ischemic optic neuropathy and compressive optic neuropathy Indian J Ophthalmol [online] 2014 Mar, 62(3):299-304 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.118452
  3. SANDERS EA, VOLKERS AC, VAN DER POEL JC, VAN LITH GH. Visual function and pattern visual evoked response in optic neuritis. Br J Ophthalmol [online] 1987 Aug, 71(8):602-608 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1041240
  4. THE OPTIC NEURITIS STUDY GROUP. Multiple Sclerosis Risk after Optic Neuritis: Final Optic Neuritis Treatment Trial Follow-Up Arch Neurol [online] 2008 Jun, 65(6):727-732 [viewed 03 October 2014] Available from: doi:10.1001/archneur.65.6.727
  5. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125
  6. HAYREH SS. Management of ischemic optic neuropathies Indian J Ophthalmol [online] 2011, 59(2):123-136 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77024
  7. VOSS E, RAAB P, TREBST C, STANGEL M. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis Ther Adv Neurol Disord [online] 2011 Mar, 4(2):123-134 [viewed 03 October 2014] Available from: doi:10.1177/1756285611398702
  8. WADIA NH, DESAI MM, QUADROS EV, DASTUR DK. Role of Vegetarianism, Smoking, and Hydroxocobalamin in Optic Neuritis Br Med J [online] 1972 Jul 29, 3(5821):264-267 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1785747
  9. ETEMADIFAR M, FATEMI A, HASHEMIJAZI H, KAZEMIZADEH A. Is it necessary to perform connective tissue disorders laboratory tests when a patient experiences the first demyelinating attack? J Res Med Sci [online] 2013 Jul, 18(7):617-620 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897031
  10. BARONAITE R, ENGELHART M, MøRK HANSEN T, THAMSBORG G, SLOTT JENSEN H, STENDER S, SZECSI PB. A Comparison of Anti-Nuclear Antibody Quantification Using Automated Enzyme Immunoassays and Immunofluorescence Assays Autoimmune Dis [online] 2014:534759 [viewed 03 October 2014] Available from: doi:10.1155/2014/534759
  11. COLLONGUES N, DE SEZE J. Current and future treatment approaches for neuromyelitis optica Ther Adv Neurol Disord [online] 2011 Mar, 4(2):111-121 [viewed 03 October 2014] Available from: doi:10.1177/1756285611398939
  12. MITTAL M, MITTAL G. Neuromyelitis Optica with NMO-IgG/Anti-AQP4 Antibody Positive: First Case Reported from Uttarakhand India J Clin Diagn Res [online] 2014 Jul, 8(7):MD03-MD04 [viewed 03 October 2014] Available from: doi:10.7860/JCDR/2014/8577.4625
  13. SøRENSEN TL, ROED H, SELLEBJERG F. Optic neuritis: chemokine receptor CXCR3 and its ligands Br J Ophthalmol [online] 2004 Sep, 88(9):1146-1148 [viewed 03 October 2014] Available from: doi:10.1136/bjo.2003.040980
  14. THOMPSON EJ, KAUFMANN P, SHORTMAN RC, RUDGE P, MCDONALD WI. Oligoclonal immunoglobulins and plasma cells in spinal fluid of patients with multiple sclerosis. Br Med J [online] 1979 Jan 6, 1(6155):16-17 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1597493
  15. MENON V, SAXENA R, MISRA R, PHULJHELE S. Management of optic neuritis Indian J Ophthalmol [online] 2011, 59(2):117-122 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77020
  16. SAXENA R, PHULJHELE S, MENON V, GADAGINAMATH S, SINHA A, SHARMA P. Clinical profile and short-term outcomes of optic neuritis patients in India Indian J Ophthalmol [online] 2014 Mar, 62(3):265-267 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.121131
  17. GONçALVES AC, GEBRIM EM, MONTEIRO ML. Imaging studies for diagnosing Graves' orbitopathy and dysthyroid optic neuropathy Clinics (Sao Paulo) [online] 2012 Nov, 67(11):1327-1334 [viewed 03 October 2014] Available from: doi:10.6061/clinics/2012(11)18
  18. JONAS JB, WANG N, XU J, WANG YX, YOU QS, YANG D, XIE XB, XU L. Diabetic Retinopathy and Estimated Cerebrospinal Fluid Pressure. The Beijing Eye Study 2011 PLoS One [online] , 9(5):e96273 [viewed 03 October 2014] Available from: doi:10.1371/journal.pone.0096273
  19. MANICKAM B, NEAGU V, KUKREJA S, BARENGOLTS E. RELATIONSHIP BETWEEN HBAIC AND CIRCULATING 25-HYDROXYVITAMIN D CONCENTRATION IN AFRICAN AMERICAN AND CAUCASIAN AMERICAN MEN Endocr Pract [online] 2013, 19(1):73-80 [viewed 03 October 2014] Available from: doi:10.4158/EP12168.OR

Investigations - Fitness for Management

Fact Explanation
ESR, CRP These basic blood investigations give an idea about the current inflammatory condition[1][2].
FBC This also important in assessing the patients current condition of haemoglobin level[2][3][4].
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[4][5].
References
  1. HAYREH SS. Management of ischemic optic neuropathies Indian J Ophthalmol [online] 2011, 59(2):123-136 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77024
  2. VOSS E, RAAB P, TREBST C, STANGEL M. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis Ther Adv Neurol Disord [online] 2011 Mar, 4(2):123-134 [viewed 03 October 2014] Available from: doi:10.1177/1756285611398702
  3. SHARMA P, SHARMA R. Toxic optic neuropathy Indian J Ophthalmol [online] 2011, 59(2):137-141 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77035
  4. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125
  5. THE OPTIC NEURITIS STUDY GROUP. Multiple Sclerosis Risk after Optic Neuritis: Final Optic Neuritis Treatment Trial Follow-Up Arch Neurol [online] 2008 Jun, 65(6):727-732 [viewed 03 October 2014] Available from: doi:10.1001/archneur.65.6.727

Investigations - Followup

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[1][2].
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[3][4].
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[5][6][7].
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[2][5][8][9].
References
  1. THE OPTIC NEURITIS STUDY GROUP. Multiple Sclerosis Risk after Optic Neuritis: Final Optic Neuritis Treatment Trial Follow-Up Arch Neurol [online] 2008 Jun, 65(6):727-732 [viewed 03 October 2014] Available from: doi:10.1001/archneur.65.6.727
  2. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125
  3. JAYARAMAN M, GANDHI RA, RAVI P, SEN P. Multifocal visual evoked potential in optic neuritis, ischemic optic neuropathy and compressive optic neuropathy Indian J Ophthalmol [online] 2014 Mar, 62(3):299-304 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.118452
  4. SANDERS EA, VOLKERS AC, VAN DER POEL JC, VAN LITH GH. Visual function and pattern visual evoked response in optic neuritis. Br J Ophthalmol [online] 1987 Aug, 71(8):602-608 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1041240
  5. VOSS E, RAAB P, TREBST C, STANGEL M. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis Ther Adv Neurol Disord [online] 2011 Mar, 4(2):123-134 [viewed 03 October 2014] Available from: doi:10.1177/1756285611398702
  6. MENON V, SAXENA R, MISRA R, PHULJHELE S. Management of optic neuritis Indian J Ophthalmol [online] 2011, 59(2):117-122 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77020
  7. SAXENA R, PHULJHELE S, MENON V, GADAGINAMATH S, SINHA A, SHARMA P. Clinical profile and short-term outcomes of optic neuritis patients in India Indian J Ophthalmol [online] 2014 Mar, 62(3):265-267 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.121131
  8. SHARMA P, SHARMA R. Toxic optic neuropathy Indian J Ophthalmol [online] 2011, 59(2):137-141 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77035
  9. WADIA NH, DESAI MM, QUADROS EV, DASTUR DK. Role of Vegetarianism, Smoking, and Hydroxocobalamin in Optic Neuritis Br Med J [online] 1972 Jul 29, 3(5821):264-267 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1785747

Management - General Measures

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[2][3].
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[4][5].
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[1][2][6].
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[1][7].
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[6][8].
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[6][9][10].
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[2][6][11][12].
References
  1. ONTANEDA D, RAE-GRANT AD. Management of acute exacerbations in multiple sclerosis Ann Indian Acad Neurol [online] 2009, 12(4):264-272 [viewed 03 October 2014] Available from: doi:10.4103/0972-2327.58283
  2. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125
  3. THE OPTIC NEURITIS STUDY GROUP. Multiple Sclerosis Risk after Optic Neuritis: Final Optic Neuritis Treatment Trial Follow-Up Arch Neurol [online] 2008 Jun, 65(6):727-732 [viewed 03 October 2014] Available from: doi:10.1001/archneur.65.6.727
  4. JAYARAMAN M, GANDHI RA, RAVI P, SEN P. Multifocal visual evoked potential in optic neuritis, ischemic optic neuropathy and compressive optic neuropathy Indian J Ophthalmol [online] 2014 Mar, 62(3):299-304 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.118452
  5. SHINDLER KS, REVERE K, DUTT M, YING GS, CHUNG DC. In Vivo Detection of Experimental Optic Neuritis by Pupillometry Exp Eye Res [online] 2012 Jul:1-6 [viewed 03 October 2014] Available from: doi:10.1016/j.exer.2012.04.005
  6. SHARMA P, SHARMA R. Toxic optic neuropathy Indian J Ophthalmol [online] 2011, 59(2):137-141 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77035
  7. FROHMAN TC, CASTRO W, SHAH A, COURTNEY A, ORTSTADT J, DAVIS SL, LOGAN D, ABRAHAM T, ABRAHAM J, REMINGTON G, TREADAWAY K, GRAVES D, HART J, STUVE O, LEMACK G, GREENBERG B, FROHMAN EM. Symptomatic therapy in multiple sclerosis Ther Adv Neurol Disord [online] 2011 Mar, 4(2):83-98 [viewed 03 October 2014] Available from: doi:10.1177/1756285611400658
  8. DE SILVA P, JAYAMANNE G, BOLTON R. Folic acid deficiency optic neuropathy: A case report J Med Case Reports [online] :299 [viewed 03 October 2014] Available from: doi:10.1186/1752-1947-2-299
  9. RAMCHANDANI S, RAMCHANDANI S, AHUJA I. Evaluation of retinal nerve fiber layer thickness measurements using optical coherence tomography in patients with tobacco-alcohol-induced toxic optic neuropathy Indian J Ophthalmol [online] 2010, 58(6):554 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.71694
  10. JOSEPH S, AL-ALI S, TRIPATHI A. Tobacco-alcohol optic neuropathy. Is complete recovery possible? Oman J Ophthalmol [online] 2014, 7(1):50 [viewed 03 October 2014] Available from: doi:10.4103/0974-620X.127948
  11. KULKARNI K, DEL PRIORE LV. Linezolid induced toxic optic neuropathy Br J Ophthalmol [online] 2005 Dec, 89(12):1664-1665 [viewed 03 October 2014] Available from: doi:10.1136/bjo.2005.074237
  12. NAGRA PK, FOROOZAN R, SAVINO PJ, CASTILLO I, SERGOTT RC. Amiodarone induced optic neuropathy Br J Ophthalmol [online] 2003 Apr, 87(4):420-422 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1771608

Management - Specific Treatments

Fact Explanation
watchful waiting The prognosis of optic neuritis is very good. Majority of patients will recover irrespective of treatments[3][4].
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[1][2][5]. 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[1][2][6].
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[1][7].
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[1][8][9].
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[10][11][12][13][14].
References
  1. ONTANEDA D, RAE-GRANT AD. Management of acute exacerbations in multiple sclerosis Ann Indian Acad Neurol [online] 2009, 12(4):264-272 [viewed 03 October 2014] Available from: doi:10.4103/0972-2327.58283
  2. PULA JH, MACDONALD CJ. Current options for the treatment of optic neuritis Clin Ophthalmol [online] 2012:1211-1223 [viewed 03 October 2014] Available from: doi:10.2147/OPTH.S28112
  3. VOSS E, RAAB P, TREBST C, STANGEL M. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis Ther Adv Neurol Disord [online] 2011 Mar, 4(2):123-134 [viewed 03 October 2014] Available from: doi:10.1177/1756285611398702
  4. MENON V, SAXENA R, MISRA R, PHULJHELE S. Management of optic neuritis Indian J Ophthalmol [online] 2011, 59(2):117-122 [viewed 03 October 2014] Available from: doi:10.4103/0301-4738.77020
  5. ROSS AP, HALPER J, HARRIS CJ. Assessing Relapses and Response to Relapse Treatment in Patients with Multiple Sclerosis: A Nursing Perspective Int J MS Care [online] 2012, 14(3):148-159 [viewed 03 October 2014] Available from: doi:10.7224/1537-2073-14.3.148
  6. DEVI BV, KISHORE CK, RAO JV, VENGAMMA B, KUMAR VS. Plasma exchange for steroid unresponsive Devic's disease Indian J Nephrol [online] 2012, 22(6):485-486 [viewed 03 October 2014] Available from: doi:10.4103/0971-4065.106050
  7. PULA JH, MACDONALD CJ. Current options for the treatment of optic neuritis Clin Ophthalmol [online] 2012:1211-1223 [viewed 03 October 2014] Available from: doi:10.2147/OPTH.S28112
  8. SHINDLER KS, VENTURA E, REX TS, ELLIOTT P, ROSTAMI A. SIRT1 Activation Confers Neuroprotection in Experimental Optic Neuritis Invest Ophthalmol Vis Sci [online] 2007 Aug, 48(8):3602-3609 [viewed 03 October 2014] Available from: doi:10.1167/iovs.07-0131
  9. DUTT M, TABUENA P, VENTURA E, ROSTAMI A, SHINDLER KS. Timing of Corticosteroid Therapy Is Critical to Prevent Retinal Ganglion Cell Loss in Experimental Optic Neuritis Invest Ophthalmol Vis Sci [online] 2010 Mar, 51(3):1439-1445 [viewed 03 October 2014] Available from: doi:10.1167/iovs.09-4009
  10. ALLEGRI P, RISSOTTO R, HERBORT CP, MURIALDO U. CNS Diseases and Uveitis J Ophthalmic Vis Res [online] 2011 Oct, 6(4):284-308 [viewed 05 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306114
  11. SMITH GT, GOLDMEIER D, MIGDAL C. Neurosyphilis with optic neuritis: an update Postgrad Med J [online] 2006 Jan, 82(963):36-39 [viewed 05 October 2014] Available from: doi:10.1136/pgmj.2004.020875
  12. ZAFAR MA, WAHEED SS, ENAM SA. Orbital aspergillus infection mimicking a tumour: a case report Cases J [online] :7860 [viewed 05 October 2014] Available from: doi:10.4076/1757-1626-2-7860
  13. HASAN S, B. BASRI H, P. HIN L, STANSLAS J. Encephalitis Followed by Optic Neuritis: A Case Report and Review of Literature Pak J Med Sci [online] 2013, 29(3):859-862 [viewed 05 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809309
  14. HONG SM, YANG YS. A Case of Optic Neuritis Complicating Herpes Zoster Ophthalmicus in a Child Korean J Ophthalmol [online] 2010 Apr, 24(2):126-130 [viewed 05 October 2014] Available from: doi:10.3341/kjo.2010.24.2.126