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