Download Case 4 Inflammatory optic neuropathy A 59-year

Case 4
Inflammatory optic neuropathy
A 59-year-old male had progressive decreased vision in the left eye for 4 days. He had pain
around the left eye and temple area.
Ocular examination revealed visual acuity of 20/20 in the right eye and no light perception in the
left eye. Anterior segment was unremarkable. The left pupil reacted sluggishly to light and there
was a left RAPD.
Left fundus examination showed generalized, hyperemic optic disc edema and peripapillary flameshaped hemorrhage.
MRIs of brain and orbit revealed abnormal T2 signal and contrast enhancement of intraorbital part
of bilateral optic nerves. There was no intracranial lesion. All blood tests and serologic work up
were negative.
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Diagnosis
: Papillitis (anterior optic neuritis)
Pathogenesis : Demyelination of the optic nerve
Etiology
: Idiopathic (Primary), viral or bacterial infection, vaccination, sarcoidosis, syphilis,
lyme disease, autoimmune diseases and vasculitides
Differential diagnosis : Anterior ischemic optic neuropathy, Infiltrative optic neuropathy,
impending central retinal vein occlusion, Leber’s hereditary optic neuropathy, optic nerve drusen
Investigation :
1. Neuroimaging : MRI brain and orbit to confirm the diagnosis of optic neuritis and to detect
demyelinating plaques in primary optic neuritis
2. Serologic tests need to be performed in atypical optic neuritis. Cerebrospinal fluid
examination may be performed.
Management :
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IV methylprednisolone 1 g/day for 3 days, followed by a 14-day schedule of oral
prednisolone for primary optic neuritis
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need long-term oral steroids or other immunosuppressive drugs or other specific treatment
for atypical cases