Eyeworld

37 EW FEATURE June 2018 • Neuro-ophthalmology for the anterior segment surgeon diagnoses in patients who did not have optic neuritis were headache, functional vision loss, and optic neuropathies, such as nonarteritic anterior ischemic optic neuropathy, traumatic optic neuropathy, and others of unclear etiology. Retinal conditions, such as central serous retinopathy, were also mistaken for optic neuritis, Dr. Van Stavern said. Features that should raise con- cern for either atypical optic neuritis or another diagnosis are an age of more than 55 years, a lack of pain, the presence of macular edema, severe disc swelling with hemorrhag- es, or something in the history or review of systems such as malignan- cy or HIV. "The lack of optic nerve dys- function, and particularly the lack of a relative afferent pupillary defect, would argue strongly against optic neuritis," Dr. Van Stavern said. In terms of treatment and recovery, both Dr. Van Stavern and Dr. Habash said most patients will recover spontaneously back to or near baseline. Based on the Optic Neuritis Treatment Trial, Dr. Van Stavern usually recommends obser- vation or treatment with high-dose IV methylprednisolone, which was shown to speed recovery, though it showed no difference in visual outcomes. A moderate dosage of oral prednisone (60 mg daily) did not, however, speed recovery and was associated with an increased risk for future optic neuritis episodes, Dr. Van Stavern noted. If there is severe vision loss upon presentation with optic neuri- tis, Dr. Van Stavern said it can raise concerns about another demyelinat- ing disorder, such as neuromyelitis optica. This can be diagnosed with a blood test. As for the risk of recurrence of optic neuritis, Dr. Van Stavern said if the MRI shows at least one lesion as- sociated with multiple sclerosis, the risk is 75% over 15 years; if the MRI looks normal, the risk of developing multiple sclerosis and/or having an- other optic neuritis episode is about 20% within 15 years. EW References 1. Stunkel L, et al. Incidence and causes of overdiagnosis of optic neuritis. JAMA Ophthal- mol. 2018;136:76–81. 2. Volpe NJ. The optic neuritis treatment trial: a definitive answer and profound impact with unexpected results. Arch Ophthalmol. 2008;126:996–9. Editors' note: Dr. Van Stavern and Dr. Habash have no financial interests related to their comments. Contact information Habash: ranya@hipaachat.com Van Stavern: vanstaverng@wustl.edu

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