Transcript PowerPoint Presentation - Updates on Optic Neuritis

Updates on Optic Neuritis
Briar Sexton
Neuro-ophthalmology Clinical Day
Friday, November 18, 2005
Introduction
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Optic neuritis
Atypical optic neuritis
Treatment of optic neuritis
Optic neuritis and MS
Optic Neuritis: Epidemiology
• Incidence: 1-5 per 100 000 per year
• Highest incidence in
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Caucasians
Countries with high latitudes: genetics?
Springtime
Ages 20-49
Women
Optic Neuritis
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Sub-acute, monocular visual loss
Painful extraocular movements
RAPD
Dyschromatopsia
Decreased contrast
sensitivity
• VF deficits
Fundus Signs of Optic Neuritis
Investigations
Based on ONTT results for “typical” optic neuritis
• Demyelination is the most common cause
• No need for laboratory investigation
– i.e. ESR, ANA
• Need to do MRI of the brain
– Assess MS risk
Atypical Optic Neuritis
• Atypical symptoms
– Unusual tempo of onset
– Absence of pain
– Co-morbidity
• Atypical signs
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Progressive decline in vision > 2/52
Severe/hemorrhagic disc edema
Uveitis: vitritis, retinitis, choroiditis
Persistent ON sheath enhancement on MRI
Fundus Photos: Atypical ON
Corticosteroid Dependent Optic
Neuritis
• Another atypical optic neuritis
– Response to steroids
– Vision falls with taper
– Requires investigation
Atypical Optic Neuritis: Work-up
• Laboratory investigations
– CBC, ESR, ANA, MHA-ATP, ACE
– Lyme, Baronella, TB skin test
• CXR
• Consider LP
• Make sure MRI images optic nerve/orbits
Visual Fields
• Central scotomas
• Paracentral scotomas
• Altitudinal defects
Neuroimaging
• MRI
– FLAIR sequencing
– Gadolinium enhancement
• Optic nerve sheath enhancement with gad
• Periventricular white matter lesions on
FLAIR
MRI: Nerve Sheath Enhancement
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MRI: White Matter Lesions
The Optic Neuritis Treatment Trial
(ONTT)
• Objective: to evaluate the role of
corticosteroids in the treatment of unilateral
optic neuritis
• Inclusion criteria: unilateral optic neuritis
The ONTT: Methods
• Randomization to one of 3 groups
1. IV steroids: 250 mg methylprednisolone qid x
3 days, oral prednisone (1mg/kg) x 11 days
2. Oral steroids: prednisone 1mg/kg/day x 14
days
3. Oral placebo: 14 days
ONTT: Results
• IV steroids
– More rapid recovery
but same endpoint
– Protective v. placebo at
2 years, not 3
• Oral prednisone
– Higher rate of new ON
attacks at 1 year
– Highest rate of relapse
at 5 years
The ONTT and Oral Prednisone
• Routing vs. Dose?
– Probably dose: Greater CD4 than CD8 effect
Prognosis
• Natural history: worsening over days to
weeks followed by spontaneous recovery
– 79% of patients begin to recover by 3/52
– 93% of patients show improvement by 5/52
• Ongoing clinical improvement to 1 year
• VEP latency improves to 2 years
Prognosis
• Severity of initial
visual loss is related to
final visual outcome
• Most recover well
– 74% ≥ 20/20
– 92% ≥ 20/40
Visual Sequelae
• Optic nerve head pallor will develop
• VF deficits may persist
• Uhtoff’s phenomenon
• Pulfrich phenomenon
Optic Neuritis Recurrence
From the ONTT
• 35% of patients experienced recurrence in the
previously affected eye or an attack in the fellow
eye at 10 years
• Recurrence rate was double in those with CDMS
• Recurrence rate highest in the oral steroid group
Sub-clinical Optic Neuritis
• Not all optic neuritis attacks are clinically
evident
• Sisto et al 2005
– VEP abnormalities in 54.4% of CD-MS
patients asymptomatic for visual impairment
• Vidovic et al 2005
– 70% of visually asymptomatic MS patients had
GVF defects consistent with optic neuritis
Optic Neuritis and MS
• Clinical diagnosis
– 2 demyelinating attacks separated in time and
space
– Sequential optic neuritis in one eye than the
other meets the criteria
– Discrete attacks in the same eye meets the
criteria
• Radiologic: Mac Donald Criteria
Optic Neuritis and MS
• Lessell et al. 1988: 58% of optic neuritis at
15 years in initially isolated cases
• 38-50% of all CDMS develops optic
neuritis at some point
Radiologic Predictors of MS
10 year ONTT data
• White matter lesions on MRI
– Risk is 22% if no baseline brain lesions
– Risk is 56% if ≥ 1 baseline lesion
– Risk increases with increasing lesions
Clinical Predictors of MS
ONTT 10 year data
• Low risk if no MRI lesions and
– Male gender
– Optic disc swelling
• No CDMS in subset with above and one of
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No pain
Severe disc edema
Peripapillary hemorrhages
Retinal exudates
Managing Optic Neuritis and MS
• Positive MRI
– Consider immunomodulatory therapy ie
interferon or glatiramer acetate
• Patients should be seen by neurology
CHAMPS Study
• Effect of Interferon B 1a treatment in
patients with optic neuritis and MRI
changes compatible with MS
– Significantly less CDMS
– Less progression of MRI lesions
Conclusions
• Patients must be investigated for
demyelination
• Remember the atypical optic neuritis