New developments in the treatment of optic neuritis

Optic Disc Swelling in Cancer Patients: Etiology and Implications

PURPOSE

To analyze the etiology and implications of optic disc swelling in cancer patients treated at a specialized tertiary cancer center in Jordan.

METHODS

This was a retrospective study of all cancer patients who had optic disc swelling between January 2019 and December 2020 at King Hussein Cancer Center (KHCC). Patients' data included age, sex, laterality, visual acuity, and the underlying cause and management for the optic disc swelling.

RESULTS

Optic disc swelling was present in 58 cancer patients (96 eyes), with 38 (65%) having bilateral involvement. Among these, 33 (57%) were female, and 43 (74%) were ≤40 years old. At diagnosis, 58 (63%) eyes had a best-corrected visual acuity (BCVA) better than 0.5, improving to 73 (76%) eyes at the last follow-up. High intracranial pressure (ICP) was the most common primary cause (30 patients/52%), followed by tumor infiltration of the optic nerve (10 patients/17%), optic nerve compression (7 patients/12%), and optic nerve inflammation (5 patients/9%). Four patients had pseudopapilledema. Among the 30 patients with high ICP, CNS tumors were predominant (21 patients/70%), with only 3 having idiopathic intracranial hypertension. Medications, including ATRA (All-Trans Retinoic Acid) and systemic steroids, contributed to increased ICP in six patients (20%). BCVA was less than 0.5 in all eyes (100%) affected by tumor infiltration, optic nerve inflammation, and ischemic optic neuropathy, while only eight eyes (14%) with optic disc swelling due to elevated ICP had a BCVA less than 0.5 (p < 0.0001). Management included steroids (53 patients/91%), acetazolamide (30 patients/52%), chemotherapy (20 patients/34%), radiation therapy (13 patients/22%), frequent lumbar punctures (12 patients/21%), and surgery (28 patients/48%). Visual acuity improved in 40 eyes (42%), with only 4 eyes (4%) experiencing deterioration. At a 12-month median follow-up period, 11 (19%) patients were dead, 10 (10%) eyes had poor vision (BCVA less than 0.1), and 21 (22%) eyes had BCVA 0.5 or better.

CONCLUSIONS

Various underlying pathologies can induce optic disc swelling in cancer patients, a grave condition capable of causing vision loss. Notably, tumor infiltration of the optic nerve tends to result in more profound visual impairment compared to papilledema due to elevated ICP. Timely detection is crucial, and immediate symptomatic treatment followed by addressing the underlying cause is essential to prevent irreversible optic nerve damage and vision loss in cancer patients.

Unilateral Acute Idiopathic Optic Neuritis With Superior Altitudinal Visual Field Defect as a Presenting Feature

Patients with acute optic neuritis typically present with acute loss of vision. We describe a case of a young lady of 25 years of age with blurring of vision in the upper visual field of the right eye with otherwise intact visual acuity as the only presenting symptom. Although altitudinal visual field defect is not unknown to be associated with acute optic neuritis, it is generally considered a relatively uncommon occurrence. Our case illustrates an unusually unique occurrence of upper altitudinal visual field defect in association with unaffected visual acuity as the sole presenting symptom of acute idiopathic unilateral optic neuritis. When an altitudinal visual field defect is a presenting feature, besides the usual vascular and compressive causes, optic neuritis should be remembered in the list of differential diagnoses.

The evaluation of patients with optic disc edema: A retrospective study

OBJECTIVE:

Optic disc edema is among major problems that neuro-ophthalmology clinics encounter. We intended to analyze patients with optic disc edema in this article.

METHODS:

Data related to the main complaint, associated systemic disease, visual acuity, characteristics of optic disc swelling, other ocular findings, topical or systemic drugs, treatment methods, follow-up examination, and related data of the patients were obtained retrospectively.

RESULTS:

There were 77 female and 23 male patients in the study. Optic disc edema was detected bilaterally in 65 patients, unilaterally in 35 patients. The duration of the symptoms until the first application was 19.82±17.18 (0–90) days. There were no systemic disorders in 74 patients but diabetes mellitus in 11 patients, hypertension in four patients, coronary artery disease in three patients, urticaria in two patients, lymphoma in one, multiple sclerosis in one patient, mastoiditis in one patient, scleroderma in one, and pregnancy in two patients were detected. While 93 patients had no additional ocular findings, 2 had uveitis, 1 had corneal dystrophy, 1 had keratoconus, 1 had cataract, 1 had previous cataract surgery, and 1 had peripheral retinal degenerations. The major etiology of the optic disc edema was idiopathic intracranial hypertension, which was detected in 44 patients. In all these patients, bilateral optic disc edema was observed and 43 patients were given oral acetazolamide and one patient oral topiramate.

CONCLUSION:

The presence of optic nerve edema should be absolutely evaluated in patients presenting with symptoms of vision loss and increased intracranial pressure. The early diagnosis with fundoscopic examination may increase visual acuity in these patients.

Incidence and Causes of Overdiagnosis of Optic Neuritis

Importance

Diagnostic error is an important source of medical error. Overdiagnosis of optic neuritis may prompt unnecessary and costly diagnostic tests, procedures, and treatments.

Objective

To assess the incidence of and characterize factors contributing to overdiagnosis of acute optic neuritis.

Design, Setting, and Participants

In this retrospective clinic-based cross-sectional study of new patient encounters, 122 patients referred for acute optic neuritis at a university-based Midwestern neuro-ophthalmology clinic between January 2014 and October 2016 were studied. Data were analyzed from September 2016 to July 2017.

Interventions

Definite diagnosis was determined by neuro-ophthalmologists. For patients with alterative diagnoses, the Diagnosis Error Evaluation and Research taxonomy tool was applied to categorize the type of diagnostic error.

Main Outcomes and Measures

The primary outcome was the primary type of diagnostic error in patients erroneously diagnosed as having optic neuritis. Secondary outcomes included final diagnosis and interventions undergone prior to referral.

Results

A total of 122 patients were referred with acute optic neuritis during the study period; 88 (72.1%) were female, and the mean (SD) age was 42.6 (14.0) years. Of these, 49 patients (40.2%; 95% CI, 31.4-49.4) were confirmed to have optic neuritis, and 73 (59.8%; 95% CI, 50.6-68.6) had an alternative diagnosis. The most common alternative diagnoses were headache and eye pain, functional visual loss, and other optic neuropathies, particularly nonarteritic anterior ischemic optic neuropathy. The most common diagnostic error was eliciting or interpreting critical elements of history, which occurred in 24 of 73 patients (33%) with alternative diagnoses. Other common errors included errors weighing or considering alternative diagnoses (23 patients [32%]), errors weighing or interpreting physical examination findings (15 patients [21%]), and misinterpreting diagnostic test results (11 patients [15%]). In patients with alterative diagnoses, 12 (16%) had normal magnetic resonance imaging findings preceding the referral, 12 (16%) had received a lumbar puncture, and 8 (11%) had received unnecessary treatment with intravenous steroids.

Conclusions and Relevance

These data suggest that nearly 60% (95% CI, 50.6-68.6) of patients referred for optic neuritis have an alternative diagnosis, with the most common errors being overreliance on a single item of history and failure to consider alternative diagnoses. Understanding pitfalls leading to overdiagnosis of optic neuritis may improve clinicians' diagnostic process.

Optic neuritis

Acute optic neuritis is the most common optic neuropathy affecting young adults. Exciting developments have occurred over the past decade in understanding of optic neuritis pathophysiology, and these developments have been translated into treatment trials. In its typical form, optic neuritis presents as an inflammatory demyelinating disorder of the optic nerve, which can be associated with multiple sclerosis. Atypical forms of optic neuritis can occur, either in association with other inflammatory disorders or in isolation. Differential diagnosis includes various optic nerve and retinal disorders. Diagnostic investigations include MRI, visual evoked potentials, and CSF examination. Optical coherence tomography can show retinal axonal loss, which correlates with measures of persistent visual dysfunction. Treatment of typical forms with high-dose corticosteroids shortens the period of acute visual dysfunction but does not affect the final visual outcome. Atypical forms can necessitate prolonged immunosuppressive regimens. Optical coherence tomography and visual evoked potential measures are suitable for detection of neuroaxonal loss and myelin repair after optic neuritis. Clinical trials are underway to identify potential neuroprotective or remyelinating treatments for acutely symptomatic inflammatory demyelinating CNS lesions.