Population-Based Incidence of Optic Neuritis in the Era of Aquaporin-4 and Myelin Oligodendrocyte Glycoprotein Antibodies

Diagnostic Utility of Kappa Free Light Chain Index in Adults With Inaugural Optic Neuritis

BACKGROUND AND OBJECTIVES

A simple, quick, and reproducible procedure for distinguishing multiple sclerosis (MS), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and neuromyelitis optica spectrum disorder (NMOSD) at inaugural optic neuritis (ION) could be highly valuable in guiding early management.

METHODS

We included all adults admitted to the MS center of Marseille for ION between March 2016 and April 2024, with CSF analysis including the kappa free light chain (K-FLC) index. Receiver operating characteristic curves were used to measure the diagnostic ability of the K-FLC index.

RESULTS

Two hundred twenty-seven adults were admitted for ION; 210 (93%) had a K-FLC index measurement. MS was diagnosed in 84 (40%); clinically isolated syndrome suggestive of MS in 77 (36.5%), including 20 with future conversion to MS (CISwc); MOGAD in 26 (12.5%); NMOSD in 13 (6%); and other inflammatory disorders in 10 (5%). A K-FLC index ≥6.7 differentiated MS/CISwc from other diagnoses with specificity 86% and sensitivity 95% (area under the curve [AUC] 0.94). A K-FLC index <4.9 differentiated MOGAD from other diagnoses with specificity 63% and sensitivity 92% (AUC 0.78) and MOGAD from MS/CISwc with specificity 96% and sensitivity 92% (AUC 0.97). Among all patients, 93 (44%) had a K-FLC index <4.9: 24 of these (26%) had MOGAD and 5 (5.5%) MS/CISwc. Among the remaining patients with a K-FLC index ≥4.9 (n = 117), 2 (1.7%) had MOGAD (K-FLC index of 7.9 and 16.2) and 99 (85%) MS/CISwc. Among patients with normal MRI (n = 96), 73 (76%) had a K-FLC index <4.9: 22 of these (30%) had MOGAD, and none showed conversion to MS. Among the remaining patients with a K-FLC index ≥4.9 (n = 23), 2 (8.5%) had MOGAD and 7 (30.5%) showed conversion to MS. The K-FLC index did not differentiate NMOSD from other diagnoses and only moderately differentiated NMO from MS/CISwc (AUC 0.80).

DISCUSSION

The K-FLC index is an accessible biomarker to guide early diagnosis in patients with ION. The probability of MOGAD in patients with ION and a K-FLC index ≥4.9 is low even in case of normal brain/spinal cord MRI.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that for patients with ION, the K-FLC index can distinguish between MS/CISwc and MOGAD.

Optic Neuropathies

OBJECTIVE

This article highlights the clinical features, evaluation, and management of optic neuropathies commonly encountered in clinical practice.

LATEST DEVELOPMENTS

Optic neuropathies encompass all conditions affecting the optic nerve, including those caused by ischemia, inflammation (including infections and autoimmune causes), elevated intracranial pressure, compression and infiltration, toxins, nutritional deficiencies, and hereditary diseases. Surgical and medical treatments targeting the specific causes of optic neuropathies are rapidly expanding, such as surgical options to address papilledema in patients with elevated intracranial pressure and the development of gene therapies for hereditary optic neuropathies. These advances underscore the importance of swift and accurate assessments to identify the cause of optic nerve dysfunction. The evaluation of the patient with an optic neuropathy begins with a careful history and examination. Signs of optic nerve dysfunction include decreased visual acuity, color vision impairment, a relative afferent pupillary defect in the affected eye, and visual field deficits. Neuroimaging of the orbits is one of the most useful tests in determining the cause of an optic neuropathy. Additional diagnostic testing and the formulation of a treatment plan should be guided by the differential diagnosis.

ESSENTIAL POINTS

Optic neuropathies are often misdiagnosed because of errors in eliciting or interpreting the history and physical examination. A systematic approach to identifying the clinical manifestations distinctive to specific optic neuropathies is imperative for directing diagnostic assessments, formulating tailored treatment regimens, and identifying broader central nervous system and systemic disorders.

Optic Neuritis

OBJECTIVE

This article reviews the most common and noteworthy inflammatory and infectious optic neuropathies, with an update on newer syndromes.

LATEST DEVELOPMENTS

We have entered an era of antibody-assisted definitions of distinct types of optic neuritis, including aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein-associated disease, with distinct pathophysiologies, prognoses, and management options. It is crucial to distinguish between these entities and other common inflammatory (eg, sarcoid or other granulomatous inflammation) or infectious optic neuropathies as appropriate therapy radically differs. These developments highlight the increasing importance of precision terminology as many of these now distinctly defined syndromes have been previously lumped together as "typical or atypical optic neuritis." An individualized evaluation and treatment approach is required.

ESSENTIAL POINTS

Multiple sclerosis-related optic neuritis is the most common form of inflammatory demyelinating optic neuritis, causing short segments of optic nerve inflammation, with an excellent visual prognosis and tendency to improve with or without high-dose steroids.Aquaporin-4 associated optic neuritis causes longitudinally extensive optic nerve inflammation and has a more guarded prognosis for visual recovery, with poor visual outcomes in untreated patients compared with multiple sclerosis or myelin oligodendrocyte glycoprotein-associated disease.Myelin oligodendrocyte glycoprotein optic neuritis also causes longitudinally extensive optic nerve inflammation with a predilection for optic disc edema and tends to be very steroid sensitive, but recurrent. Infectious optic neuropathies are important to recognize; syphilis incidence has doubled in the last decade and requires early aggressive therapy to maximize visual recovery.

Association of optic neuritis with incident depressive disorder risk in a Korean nationwide cohort

Studies have highlighted complex bidirectional relationships between autoimmune diseases and depressive disorders. Given that early mental health interventions have substantial public health implications, this study investigated association between optic neuritis, an autoimmune inflammatory disorder of the optic nerve, and risk of developing depressive disorders. Utilizing extensive national health insurance data encompassing almost the entire Korean population, this cohort study included 11,745 patients with optic neuritis and 58,725 age- and sex- matched controls between 2010 and 2017. The diagnosis of optic neuritis was confirmed using ICD-10 code H46 and patient medical records. The association with depression risk identified by ICD-10 codes F32 and F33 was assessed using Cox proportional hazards regression models after adjusting for demographics, lifestyle variables, and other comorbidities. Newly diagnosed optic neuritis was associated with an increased risk of depression (hazard ratio = 1.349, 95% confidence interval: 1.277-1.426), independent of potential confounding factors. Subgroup analysis revealed a stronger association for individuals under 50 years, males, current smokers, and those without hypertension. This association suggests that autoimmune neuroinflammatory responses impact mental health differently across demographics. These findings underscore the importance of implementing routine depression screening and developing targeted early intervention strategies for patients with optic neuritis, particularly for those with a high-risk of depression.

Prevalence of pediatric and adult optic neuritis in the United States from 2016 to 2023

BACKGROUND/OBJECTIVES

Data on the prevalence of optic neuritis (ON) is limited with reported rates between 5.5 and 115.3 per 100,000. The US data is even more limited with the largest study performed in a single county, finding a prevalence of 115.3. This study aims to fill the gap in US data on ON.

METHODS

This (2016-2023) cross-sectional study included patients with ICD-10 codes of retrobulbar neuritis, other ON, unspecified ON, and excluded those with optic papillitis, nutritional optic neuropathy, toxic optic neuropathy. Data was collected through a series of queries in a large platform (TriNetX, LLC) containing EHR data from over 113 million patients.

RESULTS

In 2023, the prevalence of ON was 51.6 per 100,000 people in the overall population. Females had a 1.31 (95% CI, 1.27-1.36) increased odds of disease compared to males. Investigating racial and ethnic breakdown, the highest prevalence was found in the Black population (57.8/100,000) (OR 1.06 (1.01-1.10)), followed by the White (54.7/100,000) (REF) and then Hispanic or Latino populations (45.8/100,000) (OR 0.84 (0.79-0.89)) in 2023. Stratified by age, those ages 45-54 had the highest prevalence (71.3/100,000). The prevalence of ON increased 1.08 (1.05-1.10) times from 2016-2023, with the greatest increase seen in the Hispanic population. Significant increases in prevalence were also seen in the 0-14, 15-24, and 25-34 age groups.

DISCUSSION

Racial, ethnic and sex disparities are apparent in the distribution of ON, with Black individuals and females affected most often, and an increasing prevalence seen in the Hispanic population. Younger subpopulations also demonstrated significant increases, warranting additional investigation.

The atypical faces of optic neuritis: neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease

PURPOSE OF REVIEW

The purpose of this article is to provide a review of neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), with a focus on what renders optic neuritis "atypical" in these two conditions. Clinical features, diagnostic criteria, and epidemiology are outlined. Acute treatments for optic neuritis, as well as immunotherapy for NMOSD and MOGAD are discussed.

RECENT FINDINGS

Updates in NMOSD and MOGAD are highlighted, with an emphasis on novel work including the new 2023 MOGAD diagnostic criteria, our evolving understanding on the epidemiology of these conditions, and recently FDA-approved NMOSD treatments. Pipeline therapies are also discussed.

SUMMARY

A thorough history and examination, supported by ancillary testing, continues to be the mainstay of optic neuritis diagnosis. Stratifying typical versus atypical optic neuritis is paramount. Within the atypical category, NMOSD and MOGAD are important considerations. Clues can point towards these diagnoses and guide steps for treatment, which is increasingly becoming targeted to individual diseases, as the pathophysiology is different for these disorders.

Long-Term Outcome and Prognosis of Idiopathic Optic Neuritis: A Cohort Study

INTRODUCTION

Patients diagnosed with optic neuritis (ON) who did not fulfil the diagnostic criteria for multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMO-SD), tested negative myelin oligodendrocyte glycoprotein immunoglobulin G and for which a systemic disease has been excluded are classified as having idiopathic ON (IDON).

METHODS

This was a monocentric retrospective observational study. Inclusion criteria were as follows: patients with IDON, absence of an alternative diagnosis during the first 2 years, follow-up of at least 5 years.

RESULTS

Thirty-six patients were included. After a median follow-up of 9 years, a diagnosis of IDON was retained for 77.8% (n = 28) of patients, whereas 22.2% (n = 8) converted to an alternative diagnosis after a median of 6 years. Four patients converted to MS, two to clinically isolated syndrome and two to seronegative NMO-SD. Among the 28 patients who remained diagnosed with IDON, 42.9% (n = 12) experienced recurrent ON, occurring mostly (90%) within the first 5 years of the disease. Maintenance therapy was initiated in 10 of the 12 patients, among whom 6 patients had no recurrence under treatment. For the 28 patients who remained with IDON, the final best corrected visual acuity (BCVA) was variable. Respectively, 35.7% and 25.9% of patients had a BCVA inferior to 0.5 and 0.2, whereas 50% recovered a final BCVA of 10/10.

CONCLUSION

A significant proportion of the cohort converted to an alternative diagnosis after 2 years, encouraging an extended follow-up of IDON patients. Maintenance therapies were often effective in case of recurrent ON.

MOG antibody-associated disease epidemiology in Olmsted County, USA, and Martinique

OBJECTIVES

To report myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) epidemiology in two American regions using 2023 diagnostic criteria.

PATIENTS AND METHODS

We compared age- and sex-adjusted incidence and prevalence of MOGAD per 2023 diagnostic criteria in Olmsted County (Minnesota [USA]) and Martinique (Caribbean [FR]) (01/01/2003-12/31/2018, prevalence day) using Poisson regression. Archived sera in 68-85% were available for MOG-IgG testing by live cell-based assay at Mayo Clinic.

RESULTS

Of 21 patients with MOG-IgG positivity identified, 16 fulfilled MOGAD criteria (38% female; median age of 27 years, interquartile-range [IQR 23-42]) and five with low-positive MOG-IgG did not (optic neuritis lacking supportive criteria, 2; alternative diagnosis of multiple sclerosis, 3). MOGAD prevalence was similar in Olmsted County (3.70/100,000, 95% confidence interval [CI] 0.74-6.66]) and Martinique (2.61/100,000; 95% CI 0.85-4.37, P = 0.46). MOGAD incidence was 3.00/million-person-years (95% CI 0.78-5.22) in Olmsted County and 1.18/million-person-years (95% CI 0.30-2.07) in Martinique (P = 0.08). Children represented 29% of MOGAD in Olmsted County and 11% in Martinique. During their disease course the attacks included: optic neuritis (13/16 [81%]); myelitis (6/16 [38%]); and acute disseminated encephalomyelitis (2/16 [13%]). The proportion of MOGAD among incident CNS demyelinating diseases was greater in children (13-14%) than adults (2-4%; P = 0.005). At last follow-up (median, 5 years, IQR 2-9), the median EDSS was 1.0 (IQR 0.5-2.75) with 1/16 (6%) blind in one eye and 9/16 (56%) had relapsing MOGAD.

CONCLUSIONS

This study provides estimates of incidence and prevalence of MOGAD in the USA and Martinique and shows that, although children are predisposed, the disease is spread broadly across the age spectrum and population-based outcomes are favorable.

One-year risk of multiple sclerosis after a first episode of optic neuritis according to modern diagnosis criteria

PURPOSE

The last updates to diagnostic criteria for multiple sclerosis (MS) included a diagnostic category of 'possible MS'. However, no recent data is available to assess how much this distinction helps predict MS after isolated optic neuritis (ON). This study aimed to assess the global risk of developing MS one year after a first ON episode, and the specific risk according to the initial diagnosis of isolated ON or ON with possible MS.

METHODS

One-year follow-up of a multicentric prospective cohort of adult patients with acute ON.

RESULTS

This study included 55 patients with acute ON of no known etiological diagnosis. Overall, the final diagnosis at one year was MS (23, 42 %), MOGAD (7, 13 %), NMOSD (1, 2 %), CRION (3, 5 %), possible MS (6, 11 %), secondary ON (3, 5 %), and strictly isolated ON (12, 22 %). Three of the 17 (18 %) patients with strictly isolated ON and 2/8 (25 %) with possible MS at baseline progressed to MS. All secondary MS diagnosis were made through radiological monitoring.

CONCLUSION

One year after the first ON episode, we observed a similar conversion rate to MS for patients with strictly isolated ON and possible MS, with a higher prevalence of MS than found by the ONTT.

Improved MR Detection of Optic Nerve Demyelination With MP2RAGE-FLAWS Compared With T2-Weighted Fat-Saturated Sequences

OBJECTIVES

Nonenhanced T1-w sequences such as magnetization-prepared 2 rapid acquisition gradient echo (MP2RAGE) and derived fluid and white matter suppression (FLAWS) have demonstrated high performance for detecting brain parenchymal and cervical spine demyelinating lesions in multiple sclerosis. However, their potential for identifying optic nerve (ON) demyelination remains unexplored. The aim of this study was to evaluate the performance of compressed sensing-accelerated (CS) MP2RAGE-FLAWS imaging for detection of ON demyelination lesions compared with T2-w fat-saturated (FS) TSE imaging in a clinical setting.

MATERIALS AND METHODS

We conducted a retrospective study of magnetic resonance scans acquired on patients with central nervous system demyelinating disorders between January and December 2022. Inclusion criteria were the acquisition in the same session of a brain CS-MP2RAGE-FLAWS imaging and a combination of axial + coronal T2-w FS orbital sequences. A 4-step radiological analysis-including blinded and consensus readings-assessed ON lesion detection. The reference standard was the final reading session of radiologists using the entire patient file. Sensitivities and specificities of both sequences were computed and compared using McNemar χ2 tests.

RESULTS

Thirty-nine patients (mean age: 43 ± 14 years; 25 women) were analyzed, including 34 with multiple sclerosis, 2 with MOGAD (myelin oligodendrocyte glycoprotein antibody-associated disease), 1 with NMOSD (neuromyelitis optica spectrum disorder), and 2 with indeterminate demyelinating disease. Among the 78 ONs analyzed, 64 lesions were detected with CS-MP2RAGE-FLAWS as opposed to 37 with 2D T2-w FS imaging, corresponding to a total of 41 and 27 affected nerves, respectively. CS-MP2RAGE-FLAWS exhibited higher sensitivity for overall detection of ON lesions compared with 2D T2-w FS imaging (97.5% vs 67.5%, P = 0.001) without reducing the specificity. Improved lesion detectability with CS-MP2RAGE-FLAWS was significant compared with 2D T2-w FS in intraorbital and intracanalicular segments (respectively, 92.3% vs 50% and 96.3% vs 66.7%; P < 0.05). There was no difference in sensitivity (P = 0.69) or specificity (P = 0.99) regarding the intracranial segment analysis.

CONCLUSIONS

CS-MP2RAGE-FLAWS sequence improves ON lesion detection compared with conventional 2D T2-w FS, especially in the intraorbital segment, while simultaneously providing whole-brain and cervical spinal cord imaging at no additional time cost.

The influence of MOGAD on diagnosis of multiple sclerosis using MRI

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is an immune-mediated demyelinating disease that is challenging to differentiate from multiple sclerosis (MS), as the clinical phenotypes overlap, and people with MOGAD can fulfil the current MRI-based diagnostic criteria for MS. In addition, the MOG antibody assays that are an essential component of MOGAD diagnosis are not standardized. Accurate diagnosis of MOGAD is crucial because the treatments and long-term prognosis differ from those for MS. This Expert Recommendation summarizes the outcomes from a Magnetic Resonance Imaging in MS workshop held in Oxford, UK in May 2022, in which MS and MOGAD experts reflected on the pathology and clinical features of these disorders, the contributions of MRI to their diagnosis and the clinical use of the MOG antibody assay. We also critically reviewed the literature to assess the validity of distinctive imaging features in the current MS and MOGAD criteria. We conclude that dedicated orbital and spinal cord imaging (with axial slices) can inform MOGAD diagnosis and also illuminate differential diagnoses. We provide practical guidance to neurologists and neuroradiologists on how to navigate the current MOGAD and MS criteria. We suggest a strategy that includes useful imaging discriminators on standard clinical MRI and discuss imaging features detected by non-conventional MRI sequences that demonstrate promise in differentiating these two disorders.

Frequency of Asymptomatic Optic Nerve Enhancement in 203 Patients With MOG Antibody-Associated Disease

BACKGROUND AND OBJECTIVES

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a distinct CNS demyelinating disease. The rate of asymptomatic optic nerve enhancement on MRI has not been explored in patients with MOGAD. An improved understanding of this would guide clinical practice and assessment of treatment efficacy. We aimed to determine the frequency of asymptomatic optic nerve enhancement in MOGAD.

METHODS

This was a retrospective review of patients evaluated at Mayo Clinic with MOGAD between January 1, 2000, and August 1, 2021 (median follow-up 1.6 [range 1-19] years). MRI studies were reviewed by masked neuroradiologists. Scans performed within 30 days of ON attack were classified as attack scans. Images obtained for routine surveillance, before ON attack, or at the time of non-ON attack were classified as interattack scans.

RESULTS

Five hundred sixty-six MRIs (203 unique patients, 53% female) were included. Interattack MRIs represented 341 (60%) of the scans (median 36 days post-ON [range -1,032 to 6,001]). Of the interattack scans, 43 of 341 (13%), 30 unique patients, showed optic nerve enhancement. The enhancement was located at prior sites of ON in 35 of 43 (81%). Among the 8 patients with enhancement in new optic nerve areas, 6 had acute disseminated encephalomyelitis without an eye examination at the time of the MRI and 2 had preceding ON without imaging. Long-term visual outcomes showed no significant difference between those with and without asymptomatic enhancement, with improved visual acuity in most patients.

DISCUSSION

Asymptomatic optic nerve enhancement occurred in 13% of interattack MRIs, the majority in patients with prior ON and occurring at prior sites of optic nerve enhancement. New asymptomatic optic nerve enhancement in areas without prior ON was rare. These findings are important for understanding the natural history of MOGAD, the interpretation of symptoms or response to treatment, and the adjudication of attacks in clinical trials.

Factors That Influence Clinician Prescribing of Corticosteroids for Acute Idiopathic and Multiple Sclerosis-Associated Optic Neuritis: A Qualitative Study

BACKGROUND

Treatment with corticosteroids is common for patients with idiopathic and multiple sclerosis-associated optic neuritis (I/MS-ON). Yet, the Optic Neuritis Treatment Trial and meta-analyses confirm that few patients benefit and that visual benefit is of questionable clinical significance, short-lived, and comes with potential harms. The purpose of this study was to uncover the breadth of factors that underlie clinicians' treatment decisions and determine how these factors may influence corticosteroid use for I/MS-ON.

METHODS

We performed semistructured, one-on-one, qualitative interviews with neurologists, neuro-ophthalmologists, and emergency department clinicians at 15 academic and private practices across the United States. The interview guide used the Theoretical Domain Framework and a vignette to explore numerous factors that might influence decision making for definite I/MS-ON. We analyzed transcripts using inductive thematic analysis to generate themes.

RESULTS

A total of 22 clinicians were interviewed before thematic saturation was reached: 8 neuro-ophthalmologists, 8 neurologists, and 6 emergency medicine (EM) clinicians (2 physician assistants, 4 physicians). All neuro-ophthalmologists and nearly all neurologists (7 of 8) were aware of risks/benefits of corticosteroid treatment for I/MS-ON. However, neuro-ophthalmologists varied in their corticosteroid treatment recommendation (n = 3 recommended treatment, n = 2 recommended observation, n = 3 recommended shared decision making), whereas all neurologists recommended corticosteroids, indicating that knowledge of corticosteroid risk/benefit alone does not drive decision making. EM clinicians were not aware of risk/benefits of corticosteroid treatment for I/MS-ON and relied on the treatment recommendations of neurologists. Clinicians recommending corticosteroids held personal beliefs that corticosteroids benefit those with worse vision loss, relieve pain, allow earlier return to work, or have easily mitigated side effects. They also perceived that prescribing steroid was the principal method of "doing something," which fit a key provider role. Clinicians who did not recommend corticosteroids or were neutral perceived the risks as nontrivial, considered discussing treatment trade-offs as "doing something" and incorporated patient preferences.

CONCLUSIONS

Knowledge of risk/benefits of corticosteroids are necessary but not sufficient for evidence-based I/MS-ON practice. Variation in how clinicians treat patients with acute I/MS-ON is influenced largely by psychosocial factors, such as beliefs about corticosteroid risk/benefit trade-offs and the role of the clinician to provide treatment. Interventions to support evidence-based decision making for I/MS-ON treatment will need to provide risk/benefit information to support clinicians with varying levels of expertise, incorporate patient preference, and normalize the option to observe.

Overview and Diagnostic Approach in Autoimmune Neurology

OBJECTIVE

The field of autoimmune neurology is rapidly evolving. This article reviews the epidemiology and pathophysiology as well as current approaches to clinical and paraclinical assessment, testing paradigms, and general principles of treatment.

LATEST DEVELOPMENTS

Improved recognition of autoimmune diagnoses among patients who have phenotypically diverse, subacute onset neurologic presentations is facilitated by disease-specific antibody biomarker discovery. These antibodies have varying associations with paraneoplastic causation (from no association to greater than 70% positive predictive value), immunotherapy responses, and outcomes. To simplify assessment in an increasingly complex discipline, neurologic phenotype-specific serum and CSF antibody evaluations are recommended. Clinical trials have led to the approval of monoclonal therapies for neuromyelitis optica spectrum disorder (NMOSD) and are underway for N-methyl-d-aspartate (NMDA) receptor and leucine-rich glioma inactivated protein 1 (LGI1) encephalitides.

ESSENTIAL POINTS

Autoimmune neurology is now a mainstream subspecialty, consisting of disorders with diverse presentations detectable using antibody testing of serum and CSF. Early and sustained immunotherapy (eg, corticosteroids, intravenous immunoglobulin [IVIg], plasma exchange) is recommended and may be supplemented by immune suppressants (eg, rituximab or cyclophosphamide) to sustain responses and optimize outcomes.

Are adverse events higher among patients with acute optic neuritis prescribed glucocorticoids? A retrospective, longitudinal cohort study

OBJECTIVE

Optic neuritis (ON) is an acute focal inflammation of the optic nerve routinely treated with glucocorticoids. We aimed to compare adverse events (AE) among glucocorticoid-treated and untreated patients in the real world to guide clinical decision making about treatment tradeoffs.

DESIGN

Retrospective, longitudinal cohort study.

SETTING

Claims study from a large, private insurer in the USA (2005-2019).

PARTICIPANTS

Adults≥18 years old with ≥1 ICD9/10 ON diagnosis with an evaluation/management visit code, and ≥6 months continuous enrolment prior to and following ON diagnosis.

INTERVENTION

Glucocorticoid prescription exposure.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was any AE within 90 days of glucocorticoid prescription. Secondary outcome was AE assessment by severity. Generalised estimating equations with logit link assessed relationships between glucocorticoid prescription and AEs. High-dimensional propensity score analyses accounted for potential confounding (eg, sociodemographics and comorbidities). Sensitivity analyses restricted the cohort to high-dose prescriptions (≥100 mg prednisone equivalent, injection/infusion), AEs within 30 days, highly specific ON definition and traditional propensity score match.

RESULTS

Of the 14 311 people with 17 404 ON claims, 66.3% were women (n=9481), predominantly White (78.2%; n=9940), with median age (IQR)=48 (37,60) years. Within 90 days of the claim, 15.7% (n=2733/17 404) were prescribed glucocorticoids. The median (IQR) prescription duration=10 (6,20) days. Any and severe AEs were higher among patients prescribed glucocorticoids versus none (any AEs: n=437/2733 (16.0%) vs n=1784/14 671 (12.2%), adjusted OR 1.33 (95% CI: 1.18 to 1.50); severe AEs: n=72/2733 (2.6%) vs n=273/14 671 (1.9%), adjusted OR 1.82 (95% CI: 1.37 to 2.35)). Sensitivity analyses were similar.

CONCLUSIONS

Real-world glucocorticoid prescriptions among ON patients were short-term, associated with a 30% relative increase in potentially serious AEs captured within healthcare encounters, including those not previously observed, such as VTE. These results can inform treatment decisions, particularly for ON patients likely to experience only marginal benefits.

Validation of the 2023 International Diagnostic Criteria for MOGAD in a Selected Cohort of Adults and Children

BACKGROUND AND OBJECTIVES

To test the performance of the 2023 myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) criteria in adults and children with inflammatory demyelinating conditions who were tested for MOG antibodies (Abs).

METHODS

This was a retrospective study of patients tested for MOG-Abs from 2018 to 2022 in 2 specialist hospitals. The inclusion criteria comprised ≥1 attendance in an adult or pediatric demyelinating disease clinic and complete clinical and MRI records. The final clinical diagnosis of MOGAD, made by the treating neurologist, was taken as the benchmark against which the new criteria were tested. The international MOGAD diagnostic criteria were applied retrospectively; they stipulate at least 1 clinical or MRI supporting feature for MOGAD diagnosis in positive fixed MOG cell-based assay without a titer. The performance MOG-Ab testing alone for MOGAD diagnosis was also assessed and compared with that of MOGAD criteria using the McNemar test.

RESULTS

Of the 1,879 patients tested for MOG-Abs, 539 (135 pediatric and 404 adults) met the inclusion criteria. A clinical diagnosis of MOGAD was made in 86/539 (16%) patients (37 adults, 49 children), with a median follow-up of 3.6 years. The MOGAD diagnostic criteria had sensitivity of 96.5% (adults 91.9%, children 100%), specificity of 98.9% (adults 98.8%, children 98.9%), positive predictive value of 94.3% (adults 89.4%, children 98%), negative predictive value of 99.3% (adults 99.2%, children 100%), and accuracy of 98.5% (adults 98.3%, children 99.2%). When compared with MOG-Ab testing alone, a difference was seen only in adults: a significantly higher specificity (98.9% vs 95.6%, p = 0.0005) and nonstatistically significant lower sensitivity (91.9% vs 100%, p = 0.08).

DISCUSSION

The international MOGAD diagnostic criteria exhibit high performance in selected patients with inflammatory demyelinating diseases (who had a high pretest probability of having MOGAD) compared with best clinical judgment; their performance was better in children than in adults. In adults, the MOGAD criteria led to an improvement in specificity and positive predictive value when compared with MOG-Ab testing alone, suggesting that the requirement of at least 1 clinical or MRI supporting feature is important. Future work should address the generalizability of the diagnostic criteria to cohorts of greater clinical diversity seen within neurologic settings.

Big Data Analysis of Inflammatory Conditions Associated With Optic Neuritis

BACKGROUND

Previous studies in the United States established multiple sclerosis (MS) as the most common cause of optic neuritis (ON). ON can be associated with other systemic inflammatory conditions including sarcoidosis, neuromyelitis optica spectrum disorder (NMOSD), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and lupus; however, prospective studies to establish risk of ON associated with these diseases are lacking. Furthermore, appropriate workup for ON is still debated.

METHODS

A deidentified electronic medical record of a tertiary care academic center was searched for ON and rheumatologic/neuro-inflammatory diseases in the medical history, diagnoses, and laboratory results; followed by the intersection of ON with each condition. We calculated frequency of systemic conditions among patients with ON and prevalence of ON in those conditions. We also calculated relative risk (RR) of underlying systemic conditions among patients with ON compared with the study patient population.

RESULTS

In 6.7 million charts, 5,344 cases of ON were identified. Among those, MS occurred most commonly (20.6%), followed by NMOSD (10.5%). Conversely, ON occurred in 98.4% of NMOSD cases, 53.3% of MOGAD, and 10.0% of MS. NMOSD (RR = 1,233), MOGAD (RR = 688), and MS (RR = 126) had the highest RR among the conditions we evaluated. The subset analysis showed similar findings.

CONCLUSIONS

The high RR for ON among patients with NMOSD and MOGAD suggests that clinical suspicion for ON should be high among patients with these conditions presenting with vision changes. Conversely, MS and NMOSD should initially be high on the differential diagnosis for any patient presenting with optic neuritis.

Acute Optic Neuropathy in Older Adults: Differentiating Between MOGAD Optic Neuritis and Nonarteritic Anterior Ischemic Optic Neuropathy

BACKGROUND AND OBJECTIVES

Myelin oligodendrocyte glycoprotein antibody-associated disease optic neuritis (MOGAD-ON) and nonarteritic anterior ischemic optic neuropathy (NAION) can cause acute optic neuropathy in older adults but have different managements. We aimed to determine differentiating factors between MOGAD-ON and NAION and the frequency of serum MOG-IgG false positivity among patients with NAION.

METHODS

In this international, multicenter, case-control study at tertiary neuro-ophthalmology centers, patients with MOGAD presenting with unilateral optic neuritis as their first attack at age 45 years or older and age-matched and sex-matched patients with NAION were included. Comorbidities, clinical presentations, acute optic disc findings, optical coherence tomography (OCT) findings, and outcomes were compared between MOGAD-ON and NAION. Multivariate analysis was performed to find statistically significant predictors of MOGAD-ON. A separate review of consecutive NAION patients seen at Mayo Clinic, Rochester, from 2018 to 2022, was conducted to estimate the frequency of false-positive MOG-IgG in this population.

RESULTS

Sixty-four patients with unilateral MOGAD-ON were compared with 64 patients with NAION. Among patients with MOGAD-ON, the median age at onset was 56 (interquartile range [IQR] 50-61) years, 70% were female, and 78% were White. Multivariate analysis showed that eye pain was strongly associated with MOGAD-ON (OR 32.905; 95% CI 2.299-473.181), while crowded optic disc (OR 0.033; 95% CI 0.002-0.492) and altitudinal visual field defect (OR 0.028; 95% CI 0.002-0.521) were strongly associated with NAION. On OCT, peripapillary retinal nerve fiber layer (pRNFL) thickness in unilateral MOGAD-ON was lower than in NAION (median 114 vs 201 μm, p < 0.001; median pRNFL thickening 25 vs 102 μm, p < 0.001). MOGAD-ON had more severe vision loss at nadir (median logMAR 1.0 vs 0.3, p < 0.001), but better recovery (median logMAR 0.1 vs 0.3, p = 0.002). In the cohort of consecutive NAION patients, 66/212 (31%) patients with NAION were tested for MOG-IgG and 8% (95% CI 1%-14%) of those had false-positive serum MOG-IgG at low titers.

DISCUSSION

Acute unilateral optic neuropathy with optic disc edema in older adults can be caused by either MOGAD-ON or NAION. Detailed history, the degree of pRNFL swelling on OCT, and visual outcomes can help differentiate the entities and prevent indiscriminate serum MOG-IgG testing in all patients with acute optic neuropathy.

Clinical profile and challenges faced in the management of optic neuritis: the Indian scenario

PURPOSE

Optic neuritis (ON) is a relatively common ophthalmic disease that has recently received renewed attention owing to immunological breakthroughs. We studied the profile of patients with ON with special reference to antibody-mediated ON and the challenges faced in its management.

METHODS

Case records of patients with ON presenting to a tertiary eye-care center in South India were analyzed. Data on demographics, presenting visual acuity (VA), clinical features, seropositivity for aquaporin-4 immunoglobulin G (AQP4-IgG) and myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG), details of magnetic resonance imaging (MRI) of orbits and brain, and treatment were collected.

RESULTS

Among 138 cases with acute ON, male: female ratio was 1:2. Isolated ON was present in 41.3% of cases. Antibody testing of sera was performed in 68 patients only due to financial limitations. Among these, 48.5% were MOG-IgG-seropositive, 11.76% were AQP4-IgG-seropositive, and 30.88% samples were double seronegative. Other causes included multiple sclerosis (n = 4), lactational ON (n = 4), tuberculosis (n = 2), invasive perineuritis (n = 2), COVID-19 vaccination (n = 2), and COVID-19 (n = 1). The mean presenting best corrected visual acuity (BCVA) was 1.31 ± 1.16 logMAR (logarithm of the minimum angle of resolution). The mean BCVA at 3 months was 0.167 ± 0.46 logMAR. Only initial VA ≤ 'Counting fingers' (CF) had a significant association with the visual outcome for final VA worse than CF. The steep cost of investigations and treatment posed challenges for many patients in the management of ON.

CONCLUSION

MOG-IgG-associated ON is common in India. Unfortunately, financial constraints delay the diagnosis and timely management of ON, adversely affecting the outcome.

Assessment of the Quality, Accountability, and Readability of Online Patient Education Materials for Optic Neuritis

Most cases of optic neuritis (ON) occur in women and in patients between the ages of 15 and 45 years, which represents a key demographic of individuals who seek health information using the internet. As clinical providers strive to ensure patients have accessible information to understand their condition, assessing the standard of online resources is essential. To assess the quality, content, accountability, and readability of online information for optic neuritis. This cross-sectional study analyzed 11 freely available medical sites with information on optic neuritis and used PubMed as a gold standard for comparison. Twelve questions were composed to include the information most relevant to patients, and each website was independently examined by four neuro-ophthalmologists. Readability was analyzed using an online readability tool. Journal of the American Medical Association (JAMA) benchmarks, four criteria designed to assess the quality of health information further were used to evaluate the accountability of each website. Freely available online information. On average, websites scored 27.98 (SD ± 9.93, 95% CI 24.96-31.00) of 48 potential points (58.3%) for the twelve questions. There were significant differences in the comprehensiveness and accuracy of content across websites (p < .001). The mean reading grade level of websites was 11.90 (SD ± 2.52, 95% CI 8.83-15.25). Zero websites achieved all four JAMA benchmarks. Interobserver reliability was robust between three of four neuro-ophthalmologist (NO) reviewers (ρ = 0.77 between NO3 and NO2, ρ = 0.91 between NO3 and NO1, ρ = 0.74 between NO2 and NO1; all p < .05). The quality of freely available online information detailing optic neuritis varies by source, with significant room for improvement. The material presented is difficult to interpret and exceeds the recommended reading level for health information. Most websites reviewed did not provide comprehensive information regarding non-therapeutic aspects of the disease. Ophthalmology organizations should be encouraged to create content that is more accessible to the general public.

Predictors of Long-Term Visual Acuity in a Modern Cohort of Patients With Acute Idiopathic and Multiple Sclerosis-Associated Optic Neuritis

BACKGROUND

For patients with idiopathic or multiple sclerosis (MS)-associated optic neuritis (ON), the largest multicenter clinical trial (Optic Neuritis Treatment Trial [ONTT]) showed excellent visual outcomes and baseline high-contrast visual acuity (HCVA) was the only predictor of HCVA at 1 year. We aimed to evaluate predictors of long-term HCVA in a modern, real-world population of patients with ON and compare with previously published ONTT models.

METHODS

We performed a retrospective, longitudinal, observational study at the University of Michigan and the University of Calgary evaluating 135 episodes of idiopathic or MS-associated ON in 118 patients diagnosed by a neuro-ophthalmologist within 30 days of onset (January 2011-June 2021). Primary outcome measured was HCVA (Snellen equivalents) at 6-18 months. Multiple linear regression models of 107 episodes from 93 patients assessed the association between HCVA at 6-18 months and age, sex, race, pain, optic disc swelling, symptoms (days), viral illness prodrome, MS status, high-dose glucocorticoid treatment, and baseline HCVA.

RESULTS

Of the 135 acute episodes (109 Michigan and 26 Calgary), median age at presentation was 39 years (interquartile range [IQR], 31-49 years), 91 (67.4%) were women, 112 (83.0%) were non-Hispanic Caucasians, 101 (75.9%) had pain, 33 (24.4%) had disc edema, 8 (5.9%) had a viral prodrome, 66 (48.9%) had MS, and 62 (46.6%) were treated with glucocorticoids. The median (IQR) time between symptom onset and diagnosis was 6 days (range, 4-11 days). The median (IQR) HCVA at baseline and at 6-18 months were 20/50 (20/22, 20/200) and 20/20 (20/20, 20/27), respectively; 62 (45.9%) had better than 20/40 at baseline and 117 (86.7%) had better than 20/40 at 6-18 months. In linear regression models (n = 107 episodes in 93 patients with baseline HCVA better than CF), only baseline HCVA (β = 0.076; P = 0.027) was associated with long-term HCVA. Regression coefficients were similar and within the 95% confidence interval of coefficients from published ONTT models.

CONCLUSIONS

In a modern cohort of patients with idiopathic or MS-associated ON with baseline HCVA better than CF, long-term outcomes were good, and the only predictor was baseline HCVA. These findings were similar to prior analyses of ONTT data, and as a result, these are validated for use in conveying prognostic information about long-term HCVA outcomes.

Optic Neuritis After COVID-19 Vaccination: An Analysis of the Vaccine Adverse Event Reporting System

BACKGROUND

To investigate the association of optic neuritis (ON) after the COVID-19 vaccines.

METHODS

Cases of ON from Vaccine Adverse Event Reporting System (VAERS) were collected and divided into the prepandemic, COVID-19 pandemic, and COVID-19 vaccine periods. Reporting rates were calculated based on estimates of vaccines administered. Proportion tests and Pearson χ 2 test were used to determine significant differences in reporting rates of ON after vaccines within the 3 periods. Kruskal-Wallis testing with Bonferroni-corrected post hoc analysis and multivariable binary logistic regression was used to determine significant case factors such as age, sex, concurrent multiple sclerosis (MS) and vaccine manufacturer in predicting a worse outcome defined as permanent disability, emergency room (ER) or doctor visits, and hospitalizations.

RESULTS

A significant increase in the reporting rate of ON after COVID-19 vaccination compared with influenza vaccination and all other vaccinations (18.6 vs 0.2 vs 0.4 per 10 million, P < 0.0001) was observed. However, the reporting rate was within the incidence range of ON in the general population. Using self-controlled and case-centered analyses, there was a significant difference in the reporting rate of ON after COVID-19 vaccination between the risk period and control period ( P < 0.0001). Multivariable binary regression with adjustment for confounding variables demonstrated that only male sex was significantly associated with permanent disability.

CONCLUSIONS

Some cases of ON may be temporally associated with the COVID-19 vaccines; however, there is no significant increase in the reporting rate compared with the incidence. Limitations of this study include those inherent to any passive surveillance system. Controlled studies are needed to establish a clear causal relationship.

Beyond Myelin Oligodendrocyte Glycoprotein and Aquaporin-4 Antibodies: Alternative Causes of Optic Neuritis

Optic neuritis (ON) is the most common cause of vision loss in young adults. It manifests as acute or subacute vision loss, often accompanied by retrobulbar discomfort or pain during eye movements. Typical ON is associated with Multiple Sclerosis (MS) and is generally mild and steroid-responsive. Atypical forms are characterized by unusual features, such as prominent optic disc edema, poor treatment response, and bilateral involvement, and they are often associated with autoantibodies against aquaporin-4 (AQP4) or Myelin Oligodendrocyte Glycoprotein (MOG). However, in some cases, AQP4 and MOG antibodies will return as negative, plunging the clinician into a diagnostic conundrum. AQP4- and MOG-seronegative ON warrants a broad differential diagnosis, including autoantibody-associated, granulomatous, and systemic disorders. These rare forms need to be identified promptly, as their management and prognosis are greatly different. The aim of this review is to describe the possible rarer etiologies of non-MS-related and AQP4- and MOG-IgG-seronegative inflammatory ON and discuss their diagnoses and treatments.

An update on optic neuritis

Optic neuritis (ON) is the most common cause of subacute optic neuropathy in young adults. Although most cases of optic neuritis (ON) are classified as typical, meaning idiopathic or associated with multiple sclerosis, there is a growing understanding of atypical forms of optic neuritis such as antibody mediated aquaporin-4 (AQP4)-IgG neuromyelitis optica spectrum disorder (NMOSD) and the recently described entity, myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD). Differentiating typical ON from atypical ON is important because they have different prognoses and treatments. Findings of atypical ON, including severe vision loss with poor recovery with steroids or steroid dependence, prominent optic disc edema, bilateral vision loss, and childhood or late adult onset, should prompt serologic testing for AQP4-IgG and MOG-IgG. Although the traditional division of typical and atypical ON can be helpful, it should be noted that there can be severe presentations of otherwise typical ON and mild presentations of atypical ON that blur these traditional lines. Rare causes of autoimmune optic neuropathies, such as glial fibrillary acidic protein (GFAP) and collapsin response-mediator protein 5 (CRMP5) autoimmunity also should be considered in patients with bilateral painless optic neuropathy associated with optic disc edema, especially if there are other accompanying suggestive neurologic symptoms/signs. Typical ON usually recovers well without treatment, though recovery may be expedited by steroids. Atypical ON is usually treated with intravenous steroids, and some forms, such as NMOSD, often require plasma exchange for acute attacks and long-term immunosuppressive therapy to prevent relapses. Since treatment is tailored to the cause of the ON, elucidating the etiology of the ON is of the utmost importance.

Accuracy of International Classification of Diseases Codes for Identifying Acute Optic Neuritis

BACKGROUND

The accuracy of International Classification of Diseases (ICD) codes for identifying cases of acute optic neuritis (aON) is not known. A prior study reported 61% accuracy for ICD code plus MRI consistent with aON within 2 months. This study determined accuracy for ICD code plus MRI within 2 months regardless of results.

METHODS

Retrospective chart review was conducted using a medical record research repository of a tertiary care institution from 1998 to 2019. Subjects with ICD-9/10 codes for ON and an MRI brain and/or orbits within 2 months of earliest (initial) ICD code were included. MRI was classified as positive or negative for aON based on report noting gadolinium-contrast enhancement. Clinical diagnosis at the time of initial code was classified as aON, prior ON, considered ON, alternative diagnosis, or unknown based on review of physician authored clinical notes within 7 days of the initial code. Accuracy of ICD code for aON, acute or prior ON, and acute, prior, or considered ON were calculated for all subjects and stratified based on MRI result.

RESULTS

Two hundred fifty-one subjects had MRI results within 2 months of their initial ON ICD code (49 positive MRI [previously reported]; 202 negative MRI). Among those with negative MRI, 32 (16%) had aON, 40 (20%) had prior ON, 19 (9%) considered ON as a diagnosis, 92 (46%) had other confirmed diagnoses, and 19 (9%) had unknown diagnosis at time of code. Considering all subjects, accuracy for ICD code was 25% for acute ON, 41% for acute or prior ON, and 48% for acute, prior, or considered ON. Positive MRI, increased number of ON ICD codes, a code given by an ophthalmologist or neurologist within 2 months, and the presence of a neurology encounter within 2 months were associated with an increased accuracy for clinical aON diagnosis.

CONCLUSIONS

In the setting of an MRI within 2 months, ICD codes for ON have low accuracy for acute ON and only slightly better accuracy for acute or prior ON. Accuracy is higher for cases with a positive MRI than those with a negative MRI, suggesting positive MRI in conjunction with ICD codes may help more accurately identify cases. Reliance on ICD and Current Procedural Terminology codes alone to identify aON cases may introduce substantial misclassification bias in claims-based research.

Visual Outcomes Following Plasma Exchange for Optic Neuritis: An International Multicenter Retrospective Analysis of 395 Optic Neuritis Attacks

PURPOSE

To evaluate the effectiveness of plasma exchange (PLEX) for optic neuritis (ON).

METHODS

We conducted an international multicenter retrospective study evaluating the outcomes of ON following PLEX. Outcomes were compared to raw data from the Optic Neuritis Treatment Trial (ONTT) using a matched subset.

RESULTS

A total of 395 ON attack treated with PLEX from 317 patients were evaluated. The median age was 37 years (range 9-75), and 71% were female. Causes of ON included multiple sclerosis (108), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) (92), aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD) (75), seronegative-NMOSD (34), idiopathic (83), and other (3). Median time from onset of vision loss to PLEX was 2.6 weeks (interquartile range [IQR], 1.4-4.0). Median visual acuity (VA) at the time of PLEX was count fingers (IQR, 20/200-hand motion), and median final VA was 20/25 (IQR, 20/20-20/60) with no differences among etiologies except MOGAD-ON, which had better outcomes. In 81 (20.5%) ON attacks, the final VA was 20/200 or worse. Patients with poor outcomes were older (P = .002), had worse VA at the time of PLEX (P < .001), and longer delay to PLEX (P < .001). In comparison with the ONTT subset with severe corticosteroid-unresponsive ON, a final VA of worse than 20/40 occurred in 6 of 50 (12%) PLEX-treated ON vs 7 of 19 (37%) from the ONTT treated with intravenous methylprednisolone without PLEX (P = .04).

CONCLUSION

Most ON attacks improved with PLEX, and outcomes were better than attacks with similar severity in the ONTT. The presence of severe vision loss at nadir, older age, and longer delay to PLEX predicted a worse outcome whereas MOGAD-ON had a more favorable prognosis. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

The neuro-ophthalmological manifestations of NMOSD and MOGAD-a comprehensive review

Optic neuritis (ON) is one of the most frequently seen neuro-ophthalmic causes of vision loss worldwide. Typical ON is often idiopathic or seen in patients with multiple sclerosis, which is well described in the landmark clinical trial, the Optic Neuritis Treatment Trial (ONTT). However, since the completion of the ONTT, there has been the discovery of aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies, which are biomarkers for neuromyelitis optica spectrum disorder (NMOSD) and MOG antibody-associated disease (MOGAD), respectively. These disorders are associated with atypical ON that was not well characterised in the ONTT. The severity, rate of recurrence and overall outcome differs in these two entities requiring prompt and accurate diagnosis and management. This review will summarise the characteristic neuro-ophthalmological signs in NMOSD and MOGAD, serological markers and radiographic findings, as well as acute and long-term therapies used for these disorders.

Acute optic neuritis: What are the clues to the aetiological diagnosis in real life?

BACKGROUND

Previous cross-sectional studies have reported distinct clinical and radiological features among the different acute optic neuritis (ON) aetiologies. Nevertheless, these reports often included the same number of patients in each group, not taking into account the disparity in frequencies of ON aetiologies in a real-life setting and thus, it remains unclear what are the truly useful features for distinguishing the different ON causes. To determine whether clinical evaluation, ophthalmological assessment including the optical coherence tomography (OCT), CSF analysis, and MRI imaging may help to discriminate the different causes of acute ON in a real-life cohort.

METHODS

In this prospective monocentric study, adult patients with recent acute ON (<1 month) underwent evaluation at baseline and 1 and 12 months, including, high- and low-contrast visual acuity, visual field assessment and OCT measurements, baseline CSF analysis and MRI.

RESULTS

Among 108 patients, 71 (65.7%) had multiple sclerosis (MS), 19 (17.6%) had idiopathic ON, 13 (12.0%) and 5 (4.6%) had myelin oligodendrocyte glycoprotein and aquaporin-4 antibodies, at last follow up respectively.At baseline, the distribution of bilateral ON, CSF-restricted oligoclonal bands, optic perineuritis, optic nerve length lesions and positive dissemination in space and dissemination in time criteria on MRI were significantly different between the four groups (p <0.001). No significant difference in visual acuity nor inner retinal layer thickness was found between the different ON aetiologies.

CONCLUSIONS

In this large prospective study, bilateral visual involvement, CSF and MRI results are the most useful clues in distinguishing the different aetiologies of acute ON, whereas ophthalmological assessments including OCT measurements revealed no significant difference between the aetiologies.

Diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disease: International MOGAD Panel proposed criteria

Serum antibodies directed against myelin oligodendrocyte glycoprotein (MOG) are found in patients with acquired CNS demyelinating syndromes that are distinct from multiple sclerosis and aquaporin-4-seropositive neuromyelitis optica spectrum disorder. Based on an extensive literature review and a structured consensus process, we propose diagnostic criteria for MOG antibody-associated disease (MOGAD) in which the presence of MOG-IgG is a core criterion. According to our proposed criteria, MOGAD is typically associated with acute disseminated encephalomyelitis, optic neuritis, or transverse myelitis, and is less commonly associated with cerebral cortical encephalitis, brainstem presentations, or cerebellar presentations. MOGAD can present as either a monophasic or relapsing disease course, and MOG-IgG cell-based assays are important for diagnostic accuracy. Diagnoses such as multiple sclerosis need to be excluded, but not all patients with multiple sclerosis should undergo screening for MOG-IgG. These proposed diagnostic criteria require validation but have the potential to improve identification of individuals with MOGAD, which is essential to define long-term clinical outcomes, refine inclusion criteria for clinical trials, and identify predictors of a relapsing versus a monophasic disease course.

Diagnosis of Optic Disc Oedema: Fundus Features, Ocular Imaging Findings, and Artificial Intelligence

Optic disc swelling is a manifestation of a broad range of processes affecting the optic nerve head and/or the anterior segment of the optic nerve. Accurately diagnosing optic disc oedema, grading its severity, and recognising its cause, is crucial in order to treat patients in a timely manner and limit vision loss. Some ocular fundus features, in light of a patient's history and visual symptoms, may suggest a specific mechanism or aetiology of the visible disc oedema, but current criteria can at most enable an educated guess as to the most likely cause. In many cases only the clinical evolution and ancillary testing can inform the exact diagnosis. The development of ocular fundus imaging, including colour fundus photography, fluorescein angiography, optical coherence tomography, and multimodal imaging, has provided assistance in quantifying swelling, distinguishing true optic disc oedema from pseudo-optic disc oedema, and differentiating among the numerous causes of acute optic disc oedema. However, the diagnosis of disc oedema is often delayed or not made in busy emergency departments and outpatient neurology clinics. Indeed, most non-eye care providers are not able to accurately perform ocular fundus examination, increasing the risk of diagnostic errors in acute neurological settings. The implementation of non-mydriatic fundus photography and artificial intelligence technology in the diagnostic process addresses these important gaps in clinical practice.

The epidemiology and burden of neuromyelitis optica spectrum disorder, multiple sclerosis, and MOG antibody-associated disease in a province in Thailand: A population-based study

BACKGROUND

Central nervous system inflammatory demyelinating diseases (CNSIDDs) have notable interracial heterogeneity. The epidemiology of CNSIDDs in Thailand, a mainland Southeast Asian country, is unknown.

OBJECTIVES

To determine the cumulative incidence, point prevalence, and disease burden of neuromyelitis optica spectrum disorder (NMOSD) and other CNSIDDs in Thailand using population-based data of Chumphon.

METHODS

Searching for CNSIDD patients at a public secondary care hospital in Chumphon, the only neurology center in the province, from January 2016 to December 2021 was implemented using relevant ICD-10-CM codes. All diagnoses were individually ascertained by a retrospective chart review. Cumulative incidence, point prevalence, attack rate, mortality rate, and disability-adjusted life years (DALYs) were calculated.

RESULTS

Aquaporin 4-IgG-positive NMOSD was the most prevalent CNSIDD in the Thai population at 3.08 (1.76-5.38) per 100,000 persons. The prevalence of multiple sclerosis (MS) followed at 0.77 (0.26-2.26) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) at 0.51(0.14-1.87) per 100,000 adults. In the pediatric population, the incidence of acute disseminated encephalomyelitis was 0.28 (0.08-1.02) per 100,000 persons/year. Among other idiopathic demyelinating diseases, idiopathic optic neuritis had the highest incidence at 0.58 (0.24-0.92) per 100,000 persons/year, followed by acute transverse myelitis at 0.44 (0.14-0.74). Idiopathic demyelinating brainstem syndrome was also observed at 0.04 (0.01-0.25) per 100,000 persons/year. Although most had a fair recovery, disability was worst among NMOSD patients with DALYs of 3.61 (3.00-4.36) years per 100,000 persons. Mortality rate was the highest in NMOSD as well.

CONCLUSION

CNSIDDs are rare diseases in Thailand. The prevalence is comparable to that of East Asian populations. A nationwide CNSIDDs registry would better elaborate the epidemiology of these diseases.

Optic neuritis: current challenges in diagnosis and management

PURPOSE OF REVIEW

The primary aim of this review is to describe the clinical course, salient imaging features, and relevant serological profiles of common optic neuritis (ON) subtypes. Key diagnostic challenges and treatment options will also be discussed.

RECENT FINDINGS

ON is a broad term that describes an inflammatory optic nerve injury arising from a variety of potential causes. ON can occur sporadically, however there is particular concern for co-associated central nervous system (CNS) inflammatory syndromes including multiple sclerosis (MS), neuromyelitis optic spectrum disorders (NMOSD), and myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD). The ON subtypes that often herald MS, NMOSD, and MOGAD differ with respect to serological antibody profile and neuroimaging characteristics, yet there is significant overlap in their clinical presentations. A discerning history and thorough examination are critical to rendering the correct diagnosis.

SUMMARY

Optic neuritis subtypes vary with respect to their long-term prognosis and accordingly, require different acute treatment strategies. Moreover, delays in identifying MOGAD, and certainly NMOSD, can be highly detrimental because affected individuals are vulnerable to permanent vision loss and neurologic disability from relapses.

Predictors of Glucocorticoid Use for Acute Optic Neuritis in the United States, 2005-2019

PURPOSE

Acute optic neuritis (ON) is variably treated with glucocorticoids. We aimed to describe factors associated with glucocorticoid use.

METHODS

In this retrospective, longitudinal cohort study of insured patients in the United States (2005-2019), adults 18-50 years old with one inpatient or ≥2 outpatient diagnoses of ON within 90 days were included. Glucocorticoid use was classified as none, any dose, and high-dose (>100 mg prednisone equivalent ≥1 days). The primary outcome was glucocorticoid receipt within 90 days of the first ON diagnosis. Multivariable logistic regression models assessed the relationship between glucocorticoid use and sociodemographics, comorbidities, clinician specialty, visit number, and year.

RESULTS

Of 3026 people with ON, 65.8% were women (n = 1991), median age (interquartile range) was 38 years (31,44), and 68.6% were white (n = 2075). Glucocorticoids were received by 46% (n = 1385); 54.6% (n = 760/1385) of whom received high-dose. The odds of receiving glucocorticoids were higher among patients with multiple sclerosis (OR 1.61 [95%CI 1.28-2.04]; P < .001), MRI (OR 1.75 [95%CI 1.09-2.80]; P = .02), 3 (OR 1.80 [95%CI 1.46-2.22]; P < .001) or more (OR 4.08 [95%CI 3.37-4.95]; P < .001) outpatient ON visits, and in certain regions. Compared to ophthalmologists, patients diagnosed by neurologists (OR 1.36 [95%CI: 1.10-1.69], p = .005), emergency medicine (OR 3.97 [95%CI: 2.66-5.94]; P < .001) or inpatient clinicians (OR 2.94 [95%CI: 2.22-3.90]; P < .001) had higher odds of receiving glucocorticoids. Use increased 1.1% annually (P < .001).

CONCLUSIONS

Demyelinating disease, care intensity, setting, region, and clinician type were associated with glucocorticoid use for ON. To optimize care, future studies should explore reasons for ON care variation, and patient/clinician preferences.

Retinal structural and microvascular changes in myelin oligodendrocyte glycoprotein antibody disease and neuromyelitis optica spectrum disorder: An OCT/OCTA study

Purpose

To compare the optical coherence tomography (OCT)/OCT angiography (OCTA) measures in patients with neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD).

Methods

Twenty-one MOG, 21 NMOSD, and 22 controls were enrolled in our study. The retinal structure [retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL)] was imaged and assessed with the OCT; OCTA was used to image the macula microvasculature [superficial vascular plexus (SVP), intermediate capillary plexus (ICP), and deep capillary plexus (DCP)]. Clinical information such as disease duration, visual acuity, and frequency of optic neuritis and disability was recorded for all patients.

Results

Compared with NMOSD patients, MOGAD patients showed significantly reduced SVP density (P = 0.023). No significant difference (P > 0.05) was seen in the microvasculature and structure when NMOSD-ON was compared with MOG-ON. In NMOSD patients, EDSS, disease duration, reduced visual acuity, and frequency of ON significantly correlated (P < 0.05) with SVP and ICP densities; in MOGAD patients, SVP correlated with EDSS, duration, reduced visual acuity, and frequency of ON (P < 0.05), while DCP density correlated with disease duration, visual acuity, and frequency of ON.

Conclusions

Distinct structural and microvascular changes were identified in MOGAD patients compared with NMOSD patients suggesting that the pathological mechanisms are different in NMOSD and MOGAD. Retinal imaging via the SS-OCT/OCTA might have the potential to be used as a clinical tool to evaluate the clinical features associated with NMOSD and MOGAD.

[Clinical features and modern diagnostic criteria of the disease associated with myelin oligodendrocyte glycoprotein antibody disease]

Demyelinating disease of the central nervous system associated with antibodies to myelin oligodendrocyte glycoprotein (MOGAD) has been proposed to be distinguished from neuromyelitis optica spectrum disorders (NMOSD) into a separate nosological form. The basis for the recognition of nosological independence was the presence of clinical features of this disease and the detection of a specific biomarker in the blood serum of patients - IgG class antibodies to MOG. The article summarizes the current data on the clinical and radiological phenotypes of MOGAD in children and adults and the features of the course of the disease. The requirements for the laboratory diagnosis of the disease and diagnostic criteria for MOGAD proposed by an international group of experts in 2023 are given.

Optic neuritis and autoimmune optic neuropathies: advances in diagnosis and treatment

Optic neuritis is an inflammatory optic neuropathy that is commonly indicative of autoimmune neurological disorders including multiple sclerosis, myelin-oligodendrocyte glycoprotein antibody-associated disease, and neuromyelitis optica spectrum disorder. Early clinical recognition of optic neuritis is important in determining the potential aetiology, which has bearing on prognosis and treatment. Regaining high-contrast visual acuity is common in people with idiopathic optic neuritis and multiple sclerosis-associated optic neuritis; however, residual deficits in contrast sensitivity, binocular vision, and motion perception might impair vision-specific quality-of-life metrics. In contrast, recovery of visual acuity can be poorer and optic nerve atrophy more severe in individuals who are seropositive for antibodies to myelin oligodendrocyte glycoprotein, AQP4, and CRMP5 than in individuals with typical optic neuritis from idiopathic or multiple-sclerosis associated optic neuritis. Key clinical, imaging, and laboratory findings differentiate these disorders, allowing clinicians to focus their diagnostic studies and optimise acute and preventive treatments. Guided by early and accurate diagnosis of optic neuritis subtypes, the timely use of high-dose corticosteroids and, in some instances, plasmapheresis could prevent loss of high-contrast vision, improve contrast sensitivity, and preserve colour vision and visual fields. Advancements in our knowledge, diagnosis, and treatment of optic neuritis will ultimately improve our understanding of autoimmune neurological disorders, improve clinical trial design, and spearhead therapeutic innovation.

Details and outcomes of a large cohort of MOG-IgG associated optic neuritis

BACKGROUND

The goal of this study was to examine the temporal relationship of eye pain to visual loss and investigate whether timing of steroid treatment affects the rate and extent of visual recovery in optic neuritis (ON) from MOG-IgG associated disease (MOGAD) in a large cohort of MOGAD patients with ON.

METHODS

This is a multicenter, retrospective cohort study of consecutive MOGAD patients with ON attacks seen from 2017 to 2021 fulfilling the following criteria: (1) clinical history of ON; (2) MOG-IgG seropositivity. ON attacks were evaluated for presence/duration of eye pain, nadir of vision loss, time to intravenous methylprednisolone (IVMP) treatment, time to recovery, and final visual outcomes.

RESULTS

There were 107 patients with 140 attacks treated with IVMP and details on timing of treatment and outcomes. Eye pain was present in 125/140 (89%) attacks with pain onset a median of 3 days (range, 0 to 20) prior to vision loss. Among 46 ON attacks treated with IVMP within 2 days of onset of vision loss, median time to recovery was 4 days (range, 0 to 103) compared to 15 days (range, 0 to 365) in 94 ON attacks treated after 2 days (p = 0.004). Those treated within 2 days had less severe VA loss at time of treatment (median LogMAR VA 0.48, range, 0.1 to 3) compared to those treated after 2 days (median LogMAR VA 1.7, range, 0 to 3; p < 0.001), and were more likely to have a VA outcome of 20/40 or better (98% vs 83%, p = 0.01). After adjustment for the initial VA at time of treatment, the differences in final VA were no longer significantly different (p = 0.14). In addition, some patients were documented to recover without steroid treatment.

CONCLUSION

This study suggests that pain precedes vision loss in the majority of ON attacks and early steroids may lead to better outcomes in MOG-IgG ON, but some patients can recover without steroid treatment. Prospective randomized clinical trials are required to confirm these findings.

Frequency of Asymptomatic Optic Nerve Enhancement in a Large Retrospective Cohort of Patients With Aquaporin-4+ NMOSD

BACKGROUND AND OBJECTIVES

Asymptomatic or persistent optic nerve enhancement in aquaporin-4 (AQP4)-immunoglobulin G (IgG)-positive neuromyelitis optica spectrum disorder (NMOSD) is thought to be rare. Improved understanding may have important implications for assessment of treatment efficacy in clinical trials and in clinical practice. Our objective was to characterize NMOSD interattack optic nerve enhancement.

METHODS

This was a retrospective cohort study performed between 2000 and 2019 (median follow-up 5.5 [range 1-35] years) of patients with AQP4-IgG-positive optic neuritis (ON) evaluated at Mayo Clinic. MRI orbits were reviewed by a neuroradiologist, neuro-ophthalmologist, and neuroimmunologist blinded to the clinical history. Interattack optic nerve enhancement (>30 days after attack) was measured. The correlation between interattack enhancement and Snellen visual acuity (VA), converted to logarithm of the minimum angle of resolution (logMAR), at attack and at follow-up were assessed.

RESULTS

A total of 198 MRI scans in 100 patients with AQP4-IgG+ NMOSD were identified, with 107 interattack MRIs from 78 unique patients reviewed. Seven scans were performed before any ON (median 61 days before attack [range 21-271 days]) and 100 after ON (median 400 days after attack [33-4,623 days]). Optic nerve enhancement was present on 18/107 (16.8%) interattack scans (median 192.5 days from attack [33-2,943]) of patients with preceding ON. On 15 scans, enhancement occurred at the site of prior attacks; the lesion location was unchanged, but the lesion length was shorter. Two scans (1.8%) demonstrated new asymptomatic lesions (prior scan demonstrated no enhancement). In a third patient with subjective blurry vision, MRI showed enhancement preceding detectable eye abnormalities on examination noted 15 days later. There was no difference in VA at preceding attack nadir (logMAR VA 1.7 vs 2.1; p = 0.79) or long-term VA (logMAR VA 0.4 vs 0.2, p = 0.56) between those with and without interattack optic nerve enhancement.

DISCUSSION

Asymptomatic optic nerve enhancement occurred in 17% of patients with NMOSD predominantly at the site of prior ON attacks and may represent intermittent blood-brain barrier breakdown or subclinical ON. New asymptomatic enhancement was seen only in 2% of patients. Therapeutic clinical trials for NMOSD require blinded relapse adjudication when assessing treatment efficacy, and it is important to recognize that asymptomatic optic nerve enhancement can occur in patients with ON.

Evaluation of the Reddesa Chart, a New Red Desaturation Testing Method, for Optic Neuritis Screening and Grading in Clinical Routine

Background

Optic neuritis usually leads to reduced color sensitivity. Most often, the change of red color, the so-called red desaturation, is tested in clinical routine. The aim of this study was to test the feasibility of the Reddesa chart, a new red desaturation test based on polarization, as a screening method for optic neuropathy.

Methods

A total of 20 patients with unilateral optic neuritis and 20 healthy controls were included in this prospective pilot study. Ophthalmological examination included assessment of best corrected visual acuity (BCVA), slit lamp examination, fundoscopy, testing of relative afferent pupillary defect (RAPD) and red desaturation with the red cup test and the Reddesa chart.

Results

The mean BCVA in the optic neuritis group was 0.76 ± 0.36 in the affected eye (95% of eyes with RAPD, 75% of eyes with difference in the Reddesa test) and 1.28 ± 0.24 in the healthy eye, whereas in the control group, BCVA was 1.14 ± 0.11 in the right eye and 1.15 ± 0.14 in the left eye (none of the eyes with RAPD or abnormal Reddesa test). In our study, the Reddesa test showed a positive predictive value of 100% and a negative predictive value of 80% for detecting optic neuritis.

Conclusion

The Reddesa chart allows to quantify red desaturation and has the potential to be implemented as a screening test in clinical routine.

Vision Prognosis and Associated Factors of Optic Neuritis in Dependence of Glial Autoimmune Antibodies

PURPOSE

To assess the visual prognosis of optic neuritis (ON) in dependence of the glial autoimmune antibody status and associated factors.

DESIGN

Longitudinal observational cohort study.

METHODS

Patients with ON and measurements of serum concentrations of glial autoantibodies were consecutively and longitudinally examined with a minimal follow-up of 3 months. Patients with multiple sclerosis and double seronegative results were excluded.

RESULTS

The study included 529 patients (aquaporin-4 immunoglobulin [AQP4-IgG] seropositive, n = 291; myelin oligodendrocyte glycoprotein immunoglobulin [MOG-IgG] seropositive, n = 112; double-seronegative, n = 126) with 1022 ON episodes (AQP4-IgG seropositive, n = 550; MOG-IgG seropositive, n=254; double-seronegative, n = 218). Prevalence of severe vision loss (best-corrected visual acuity [BCVA] ≤20/200 at the end of follow-up) was higher (P < .001) in the AQP4-IgG group (236/550; 42.9%) than in the seronegative group (68/218; 31.2%) and in the MOG-IgG group (15/254; 5.9%). Prevalence of good vision recovery (BCVA≥20/40) was higher (P < .001) in the MOG-IgG group (229/254; 90.2%) than in the seronegative group (111/218; 50.9%) and in the AQP4-IgG group (236/550; 42.9%). In multivariable logistic analysis, higher prevalence of severe vision loss was associated with AQP4-IgG seropositivity (odds ratio [OR] 1.66; 95% CI 1.14, 2.43; P = .008), male sex (OR 1.97, 95% CI 1.33, 2.93; P < .001), age at ON onset >45 years (OR 1.93, 95% CI 1.35, 2.77; P < .001), nadir vision ≤20/200 (OR 14.11, 95% CI 6.54, 36.93; P < .001), and higher number of recurrences (OR 1.35, 95% CI 1.14, 1.61; P = .001). Higher prevalence of good vision outcome was associated with MOG-IgG seropositivity (OR 8.13, 95% CI 4.82, 14.2; P < .001), age at ON onset <18 years (OR 1.78, 95% CI 1.18, 2.71; P = .006), nadir visual acuity ≥20/40 (OR 4.03; 95% CI 1.45, 14.37; P = .015), and lower number of recurrences (OR 0.60; 95% CI 0.50, 0.72; P < .001).

CONCLUSION

Severe vision loss (prevalence in the AQP4-IgG group, MOG-IgG group, and seronegative group: 42.9%, 5.9%, and 31.2%, respectively) was associated with AQP4-IgG seropositivity, male gender, older age at onset, worse nadir vision, and higher number of recurrences.

Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD): A Review of Clinical and MRI Features, Diagnosis, and Management

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is the most recently defined inflammatory demyelinating disease of the central nervous system (CNS). Over the last decade, several studies have helped delineate the characteristic clinical-MRI phenotypes of the disease, allowing distinction from aquaporin-4 (AQP4)-IgG-positive neuromyelitis optica spectrum disorder (AQP4-IgG+NMOSD) and multiple sclerosis (MS). The clinical manifestations of MOGAD are heterogeneous, ranging from isolated optic neuritis or myelitis to multifocal CNS demyelination often in the form of acute disseminated encephalomyelitis (ADEM), or cortical encephalitis. A relapsing course is observed in approximately 50% of patients. Characteristic MRI features have been described that increase the diagnostic suspicion (e.g., perineural optic nerve enhancement, spinal cord H-sign, T2-lesion resolution over time) and help discriminate from MS and AQP4+NMOSD, despite some overlap. The detection of MOG-IgG in the serum (and sometimes CSF) confirms the diagnosis in patients with compatible clinical-MRI phenotypes, but false positive results are occasionally encountered, especially with indiscriminate testing of large unselected populations. The type of cell-based assay used to evaluate for MOG-IgG (fixed vs. live) and antibody end-titer (low vs. high) can influence the likelihood of MOGAD diagnosis. International consensus diagnostic criteria for MOGAD are currently being compiled and will assist in clinical diagnosis and be useful for enrolment in clinical trials. Although randomized controlled trials are lacking, MOGAD acute attacks appear to be very responsive to high dose steroids and plasma exchange may be considered in refractory cases. Attack-prevention treatments also lack class-I data and empiric maintenance treatment is generally reserved for relapsing cases or patients with severe residual disability after the presenting attack. A variety of empiric steroid-sparing immunosuppressants can be considered and may be efficacious based on retrospective or prospective observational studies but prospective randomized placebo-controlled trials are needed to better guide treatment. In summary, this article will review our rapidly evolving understanding of MOGAD diagnosis and management.

Comparison of 1.5 Tesla and 3.0 Tesla Magnetic Resonance Imaging in the Evaluation of Acute Demyelinating Optic Neuritis

BACKGROUND

Optic neuritis (ON) is the most common optic neuropathy in young adults. MRI is reported to have a high sensitivity for ON. Higher signal strengths of MRI may enhance resolution and lead to better detection of ON. We sought to compare the sensitivity of 3.0 Tesla (T) MRI to that of 1.5 T MRI in detecting acute demyelinating ON.

METHODS

A retrospective chart review was performed on patients with a clinical diagnosis of optic neuritis at Mayo Clinic Health System from January 2010 to April 2020. Among 1,850 patients identified, 126 patients met the eligibility criteria. Exclusion criteria comprised questionable or alternative diagnosis, diagnosis of ON before the study period, eye examinations performed elsewhere, or absence of fat-saturated head and orbits MRIs performed locally within 30 days of symptom onset. Gadolinium contrast enhancement, T2 hyperintensity, and the radiologic diagnosis of ON were recorded by a neuro-radiologist who was masked to the clinical history and the magnet strength of the MRI.

RESULTS

Fifty-three patients (42.1%) had 3.0 T MRI, and 73 patients (57.9%) had 1.5 T MRI. Overall, 88.9% (112/126) of patients were determined to have a positive MRI for ON. The radiographic sensitivity for ON was higher in the 3.0 T group compared with the 1.5 T group (98.1% vs 82.2%, respectively [P = 0.004]). The frequency of gadolinium enhancement was found to be greater in the 3 T group compared with the 1.5 T group (98.1% vs 76.7%, respectively [P < 0.001]). T2 hyperintensity was also more often seen in the 3.0 T group compared with the 1.5 T group (88.7% vs 68.5%, respectively [P = 0.01]).

CONCLUSIONS

3.0 T MRI is more sensitive than 1.5 T MRI in detecting ON. This finding suggests that 3.0 T MRI is a preferred imaging modality for the confirmation of ON.

No Light Perception Vision in Neuro-Ophthalmology Practice

BACKGROUND

To determine differential diagnosis and visual outcomes of patients with no light perception (NLP) vision related to neuro-ophthalmic conditions.

METHODS

Retrospective case series of patients seen at tertiary neuro-ophthalmology practices. Patients were included if they had NLP vision any time during their clinical course. Outcome measures were final diagnosis, treatment, and visual outcome.

RESULTS

Seventy-two eyes of 65 patients were included. The average age was 57.6 (range 18-93) years, and 58% were women. The Most common diagnosis (21 patients) was compressive optic neuropathy (CON) with meningioma being the most common culprit (12). Other diagnoses included optic neuritis (ON) (11 patients), infiltrative optic neuropathies (8), posterior ischemic optic neuropathy (7), nonarteritic anterior ischemic optic neuropathy (4), arteritic anterior ischemic optic neuropathy (3), ophthalmic artery occlusion (3), nonorganic vision loss (3), radiation-induced optic neuropathy (2), cortical vision loss (1), retinitis pigmentosa with optic disc drusen (1), and infectious optic neuropathy (1). Ten patients recovered vision: 7 ON, 2 infiltrative optic neuropathy, and 1 CON. Corticosteroids accelerated vision recovery in 7 of the 11 patients with ON to mean 20/60 (0.48 logMAR) over 9.0 ± 8.6 follow-up months. Eleven patients deteriorated to NLP after presenting with at least LP; their diagnoses included CON (3), ophthalmic artery occlusion (2), infiltration (2), ON (1), posterior ischemic optic neuropathy (1), arteritic anterior ischemic optic neuropathy (1), and radiation-induced optic neuropathy (1).

CONCLUSIONS

NLP vision may occur because of various diagnoses. Vision recovery was mainly seen in patients with ON. Serious systemic conditions may present or relapse with NLP vision, which clinicians should consider as an alarming sign in patients with known malignancies.

OCT retinal nerve fiber layer thickness differentiates acute optic neuritis from MOG antibody-associated disease and Multiple Sclerosis: RNFL thickening in acute optic neuritis from MOGAD vs MS

BACKGROUND

Optic neuritis (ON) is the most common manifestation of myelin oligodendrocyte glycoprotein antibody associated disorder (MOGAD) and multiple sclerosis (MS). Acute ON in MOGAD is thought to be associated with more severe optic disk edema than in other demyelinating diseases, but this has not been quantitatively confirmed. The goal of this study was to determine whether optical coherence tomography (OCT) can distinguish acute ON in MOGAD from MS, and establish the sensitivity of OCT as a confirmatory biomarker of ON in these entities.

METHODS

This was a multicenter cross-sectional study of MOGAD and MS patients with peripapillary retinal nerve fiber layer (pRNFL) thickness measured with OCT within two weeks of acute ON symptom. Cirrus HD-OCT (Carl Zeiss Meditec, Inc. Dublin, CA, USA) was used to measure the pRNFL during acute ON. Eyes with prior ON or disk pallor were excluded. A receiver operating characteristic (ROC) curve analysis was performed to assess the ability of pRNFL thickness to distinguish MOGAD from MS.

RESULTS

Sixty-four MOGAD and 50 MS patients met study inclusion criteria. Median age was 46.5 years (interquartile range [IQR]: 34.3-57.0) for the MOGAD group and 30.4 years (IQR: 25.7-38.4) for the MS group (p<0.001). Thirty-nine (61%) of MOGAD patients were female compared to 42 (84%) for MS (p = 0.007). The median pRNFL thickness was 164 µm (IQR: 116-212) in 96 acute MOGAD ON eyes compared to 103 µm (IQR: 93-113) in 51 acute MS ON eyes (p<0.001). The ROC area under the curve for pRNFL thickness was 0.81 (95% confidence interval 0.74-0.88) to discriminate MOGAD from MS. The pRNFL cutoff that maximized Youden's index was 118 µm, which provided a sensitivity of 74% and specificity of 82% for MOGAD. Among 31 MOGAD and 48 MS eyes with an unaffected contralateral eye or a prior baseline, the symptomatic eye had a median estimated pRNFL thickening of 45 µm (IQR: 17-105) and 7.5 µm (IQR: 1-18), respectively (p<0.001). All MOGAD affected eyes had a ≥ 5 µm pRNFL thickening, whereas 26 (54%) MS affected eyes had a ≥ 5 µm thickening.

CONCLUSION

OCT-derived pRNFL thickness in acute ON can help differentiate MOGAD from MS. This can aid with early diagnosis and guide disease-specific therapy in the acute setting before antibody testing returns, and help differentiate borderline cases. In addition, pRNFL thickening is a sensitive biomarker for confirming acute ON in MOGAD, which is clinically helpful and could be used for adjudication of attacks in future MOGAD clinical trials.

Simultaneous screening for antibodies to myelin oligodendrocyte glycoprotein and aquaporin-4 in patients with optic neuritis using cell-based assay

Background: This study was aimed to test simultaneous detection of antibodies to myelin oligodendrocyte glycoprotein (MOG)/aquaporin4 (AQP4) in serum samples of patients with clinically-diagnosed optic neuritis (ON), by fixed cell-based immunofluorescence assay (CBIFA). Methods: The study involved 237 serum samples of patients with ON which were tested for MOG and AQP4 antibodies using fixed CBIFA kit which utilizes AQP4 or MOG protein transfected cells as a substrate. Results: Of 237 serum samples, 22 (9%) were positive for AQP4, 66 (28%) were positive for MOG, and 138 (58%) were negative for both AQP4 and MOG antibodies. 11 (5%) patients with clinically-diagnosed multiple sclerosis (MS) were negative for both antibodies. None of the samples were positive for both AQP4 and MOG. Among 237, 132 women [18 (13.6%) and 37 (28%)] and 105 men [4 (3.8%) and 29 (27.6%)] were positive for AQP4/MOG antibodies and remaining percentage belonged to double negative and MS. Seropositivity rate was higher in women than men. Antibodies to MOG were significantly higher than AQP4 antibodies and evenly found in all age groups. There was no ambiguous result encountered in the study. Conclusion: In this study, the seropositivity for antibodies to MOG is more than AQP4 antibody in patients with ON. Fixed CBIFA is a useful tool for laboratory diagnosis of ON in the clinical setting of neuro-ophthalmology to plan the next line of treatment management effectively.