Treatment of acute demyelinating optic neuritis

The role of magnetic resonance imaging and visual evoked potential in management of optic neuritis

Introduction

To report our experience in management of patients with optic neuritis. The effects of brain magnetic resonance imaging and visual evoked potential on management were investigated

Methods

This is a four years clinical trial that included patients presenting with first attack of optic neuritis older than 16 years with visual acuity of less than 6/60 and presentation within first week of illness. Brain magnetic resonance imaging and visual evoked potentials were done for all patients. Patients were classified into three groups. First group received placebo, second received oral steroids and third received intravenous and oral steroids. Primary outcome measure was improvement in visual acuity.

Results

A total number of 150 patients were enrolled in the study. Ocular pain was seen 127 patients Relative afferent pupillary defect in 142 patients and color vision impairment in 131 patients. Abnormal MRI findings were seen in 84 patients. Pattern reversal VEP was abnormal in all patients. Using oral or intravenous steroid resulted in faster recovery but did not affect the final visual outcome. Recurrence rate was higher in patients with multiple MRI lesions and diminished VEP amplitude. Using intravenous steroids decreased recurrence rate in patients with three and more MRI lesions and non recordable VEP response.

Conclusion

MRI and pattern reversal VEP are recommended to be done in all patients presenting with optic neuritis. We advise to give intravenous methyl prednisolone in patients with multiple MRI white matter lesions and non recordable VEP at presentation.

Neuro-Ophthalmic Emergencies for the Neurologist

A variety of acute neurologic disorders present with visual signs and symptoms. In this review the authors focus on those disorders in which the clinical outcome is dependent on timely and accurate diagnosis. The first section deals with acute visual loss, specifically optic neuritis, ischemic optic neuropathy (ION), retinal artery occlusion, and homonymous hemianopia. The authors include a discussion of those clinical features that are helpful in distinguishing between inflammatory and ischemic optic nerve disease and between arteritic and nonarteritic ION. The second section concerns disc edema with an emphasis on the prevention of visual loss in patients with increased intracranial pressure. The third section deals with abnormal ocular motility, and includes orbital inflammatory disease, carotid-cavernous fistulas, painful ophthalmoplegia, conjugate gaze palsies, and neuromuscular junction disorders. The final section concerns pupillary abnormalities, with a particular emphasis on the dilated pupil and on carotid artery dissection. Throughout there are specific guidelines for the management of these disorders, and areas are highlighted in which there is ongoing controversy.