optic neuritis
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Optic NeuritisOptic Neuritis
Robert H. Spector, MDRobert H. Spector, MD
Visual PathwayVisual Pathway
Seeing
Looking
• Fixation When You are in Motion
When the Object is in Motion
When You and the Object are in Motion
Two optic nerves = 2.4 million Two optic nerves = 2.4 million fibersfibers
Man is a Seeing Man is a Seeing AnimalAnimal
Five Five SensesSenses
SeeingSeeingHearingHearingTouchTouchSmellSmellTasteTaste
Each ear = 30,000 nerve Each ear = 30,000 nerve fibersfibers
HearinHearingg
Two ears = 60,000 nerve Two ears = 60,000 nerve fibersfibers
Seeing 2.4 Seeing 2.4 millionmillion
Hearing 60,000Hearing 60,000= = 4040::11
SeeingSeeingEach optic nerve = 1.2 million Each optic nerve = 1.2 million fibersfibers
Cerebral HemispheresCerebral Hemispheres
CerebellumCerebellum
BrainstemBrainstem
Seeing and LookingSeeing and Looking
Response = Image
Response = Image
Stimulus = Light
Stimulus = Light
Cerebral HemispheresCerebral Hemispheres
Visual ReflexStimulusResponse
Visual ReflexStimulusResponse
Seeing
Eye Catches the Image
In Peripheral Vision
Looking
Moves the Eyes to Find the Image and Lock on
SeeingSeeingGray matterGray matter
White matterWhite matter
Gray MatterGray Matter
WhiteWhite
Optic Nerve is White Matter Optic Nerve is White Matter
In the Eyepapilla or optic disc
In the Eyepapilla or optic disc
Behind Eye retrobulbarretro=behind
bulbar= eyeball
Behind Eye retrobulbarretro=behind
bulbar= eyeball
Papilla or Optic DiscPapilla or Optic Disc
maculamacula
maculamaculamaculamacula
The Optic DiscThe Optic Disc
Inspection of the Optic Disk
Inspection of the Optic Disk
•Size
•Color
•Cup
•Vessels
•Nerve Fiber Layer
•Size
•Color
•Cup
•Vessels
•Nerve Fiber Layer
NerveFiberLayer(NFL)
Normal NFL Loss of NFL
Nerve Fiber Layer Loss: subtleNerve Fiber Layer Loss: subtle
Visual Acuity
Visual Field
Color Vision
Afferent Pupil
“Depression of
Central Vision”
“Depression of
Central Vision”
Hallmark of Optic NeuritisHallmark of Optic Neuritis
How Do We Measure How Do We Measure Central VisionCentral Vision
How Do We Measure How Do We Measure Central VisionCentral Vision
Visual Acuity: Ability to discriminate a target in the very center of visual field: 2-4 degreesVisual Acuity: Ability to discriminate a target in the very center of visual field: 2-4 degrees
Loss of Visual Acuity
Expressed as Ratio20/20
20/100
distance/letter size
Loss of Visual Acuity
Expressed as Ratio20/20
20/100
distance/letter size
Visual Field: the expanse of vision looking straight ahead at a fixed target with one eyeVisual Field: the expanse of vision looking straight ahead at a fixed target with one eye
targettarget
Visual Field “Island of Vision in a Sea of Blindness”
Visual Field “Island of Vision in a Sea of Blindness”
✈✈✈✈
♂♂
Visual Acuity
Visual Field
Color Vision
Afferent Pupil
“Depression of
Central Vision”
“Depression of
Central Vision”
Hallmark of Optic NeuritisHallmark of Optic Neuritis
How Do We Measure How Do We Measure Central VisionCentral Vision
How Do We Measure How Do We Measure Central VisionCentral Vision
Depressed Color PerceptionDepressed Color Perception
Afferent Pupil Defect (APD) or Marcus Gunn Sign
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
Visual Acuity
Visual Field
Color Vision
Afferent Pupil
“Depression of
Central Vision”
“Depression of
Central Vision”
Hallmark of Optic NeuritisHallmark of Optic Neuritis
How Do We Measure How Do We Measure Central VisionCentral Vision
How Do We Measure How Do We Measure Central VisionCentral Vision
Causes of Optic Neuropathy
Causes of Optic Neuropathy
• MS
• Infections: Lyme, Syphilis
• Granulomatous: Sarcoid, Tuberculosis
• Vascular: stroke
• Neoplastic: cancer
• Iatrogenic: postoperative complication
• Inflammatory: systemic lupus erythematosus
• Toxic: methylalcohol
• Dietary: B12 deficiency
• Traumatic
• MS
• Infections: Lyme, Syphilis
• Granulomatous: Sarcoid, Tuberculosis
• Vascular: stroke
• Neoplastic: cancer
• Iatrogenic: postoperative complication
• Inflammatory: systemic lupus erythematosus
• Toxic: methylalcohol
• Dietary: B12 deficiency
• Traumatic
MS is But One Cause of Optic Neuritis It is Not the Only Cause
MS is But One Cause of Optic Neuritis It is Not the Only Cause
Optic Neuritis = Inflammation of the Optic
NerveOptic Neuritis = Inflammation of the Optic
Nerve
… itis = inflammation: meningitis, appendicitis, gastritis, hepatitis
… itis = inflammation: meningitis, appendicitis, gastritis, hepatitis
Syphilis Rocky Mt. Spotted
FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Syphilis Rocky Mt. Spotted
FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Many CausesMany Causes
• Loss of central visual field
• Loss of visual acuity
• Loss of color perception
• Afferent Pupil
• Loss of central visual field
• Loss of visual acuity
• Loss of color perception
• Afferent Pupil
retro=behindbulbar= eyeball
Two Forms of Optic Neuritis
• Papillitis
• Retrobulbar Neuritis
Two Forms of Optic Neuritis
• Papillitis
• Retrobulbar Neuritis
Optic NerveOptic Nerve
Both Forms of Optic NeuritisBoth Forms of Optic Neuritis
papillaoptic disc
papillaoptic disc retrobulbarretrobulbar
PapillitisPapillitis Optic Disc is SwollenOptic Disc is Swollen
•Loss of central visual field
•Loss of visual acuity
•Loss of color perception
•Afferent Pupil
•Loss of central visual field
•Loss of visual acuity
•Loss of color perception
•Afferent Pupil
Retrobulbar NeuritisRetrobulbar Neuritis Optic Disc is FlatOptic Disc is Flat
•Loss of central visual field
•Loss of visual acuity
•Loss of color perception
•Afferent Pupil
•Loss of central visual field
•Loss of visual acuity
•Loss of color perception
•Afferent Pupil
•Accurate diagnosis
•Further Evaluation
•MRI, blood work, spinal fluid analysis
•Acute Treatment:
•Intravenous Methylprednisolone
•Intramuscular ACTHAR
• •
Long-term Treatment
•Clinically Isolated Syndrome
•Accurate diagnosis
•Further Evaluation
•MRI, blood work, spinal fluid analysis
•Acute Treatment:
•Intravenous Methylprednisolone
•Intramuscular ACTHAR
• •
Long-term Treatment
•Clinically Isolated Syndrome
Issues Regarding Optic NeuritisIssues Regarding Optic Neuritis
Syphilis Rocky Mt. Spotted
FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Syphilis Rocky Mt. Spotted
FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Issues Regarding Optic NeuritisIssues Regarding Optic Neuritis
•Accurate Diagnosis
•Further Evaluation
•Accurate Diagnosis
•Further Evaluation
Syphilis Rocky Mt. Spotted FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Syphilis Rocky Mt. Spotted FeverSystemic Lupus (SLE)MSMedication-induced Lyme diseaseVasculitisSarcoid
Conditions Often Misdiagnosed as Optic Neuritis Conditions Often Misdiagnosed as Optic Neuritis
Cat Scratch Optic Neuritis
Cat Scratch Optic Neuritis
ExudatesExudates
MS -- Not the Only Cause of Optic Neuritis
MS -- Not the Only Cause of Optic Neuritis
full face tfull face t
Pitfalls in Ordering an MRI
Pitfalls in Ordering an MRI
46-yo woman with Progressive Visual Loss in her Left eye
46-yo woman with Progressive Visual Loss in her Left eyeInterpretation: Normal MRIInterpretation: Normal MRI
Brain MRIBrain MRI
Exit 12Exit 12285285MRIMRI
fat suppressionfat suppression
contrast agent contrast agentthin sections of the optic nervethin sections of the optic nerve
MRI Scan Proper Technique
For Identifying MS
MRI Scan Proper Technique
For Identifying MS
MRI with Proper Technique MRI with Proper Technique
Retrobulbar Neuritis
Retrobulbar Neuritis
Acute Treatment of Visual Loss from Optic
Neuritis
Acute Treatment of Visual Loss from Optic
Neuritis
• Intravenous Methylprednisolone
•ACTHAR
• Intravenous Methylprednisolone
•ACTHAR
MaintenanceMaintenance
•Subcutaneous
• Intramuscular
• Intravenous
•Oral
•Symptomatic
•Subcutaneous
• Intramuscular
• Intravenous
•Oral
•Symptomatic
MRI in MSMRI in MS•Initial Diagnosis
•Predictive Value
•Helps Determine Effectiveness of Therapy
•Initial Diagnosis
•Predictive Value
•Helps Determine Effectiveness of Therapy
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