Concurrent Tuberculous Optic Neuritis and Optic Perineuritis in a Patient With Human Immunodeficiency Virus (HIV)

Concurrent tuberculous optic neuritis (ON) and optic perineuritis (OPN) in a patient with human immunodeficiency virus (HIV) is extremely rare. HIV-induced progressive CD4 depletion is associated with an increased risk of tuberculosis (TB), disseminated TB, and death. Early detection and initiation of anti-TB therapy with corticosteroid commencement helps in achieving better visual outcomes. Interestingly, we report a case of concurrent ON and OPN in a patient with HIV-TB co-infection. A 29-year-old lady, a prisoner, with newly diagnosed treatment-naive HIV, presented with acute-onset reduced vision in the left eye for 10 days. It was associated with pain in eye movement and headache. The patient was known to be a drug abuser since the age of 19 years and was a sexual worker. Her CD4 count was 292 cells/mm3.Visual acuity of the right eye was 6/12 with a pinhole of 6/9, and there was no perception of light (NPL) in all four quadrants of the left eye. Relative afferent pupillary defect (RAPD) was positive in the left eye. Both anterior segments were unremarkable. The right eye fundoscopy showed a normal optic disc, while the left eye showed a hyperemic disc. During subsequent follow-up, the patient had reduced right eye vision, and the vision dropped to 6/30 with a pinhole of 6/15. Her erythrocyte sedimentation rate (ESR) was raised to 88 mm/h. The Mantoux test was positive. Chest radiography was normal. MRI of the brain and orbit showed significant enhancement of the right optic nerve and left optic nerve sheath suggesting the diagnosis of right eye ON and left eye OPN secondary to TB. The patient was co-managed with an infectious disease team. She was started on highly active antiretroviral therapy (HAART) treatment (oral Tenvir-EM and efavirenz) upon presentation. Anti-TB therapy was commenced two months later. She was started on the intensive phase of the anti-TB regime followed by the maintenance phase. Oral dexamethasone was given concurrently according to the central nervous system (CNS) TB regime for six weeks. During follow-up, her right eye visual acuity was 6/9, and her left eye visual acuity improved to 6/12. Fundoscopy showed bilateral pale discs. To date, no episodes of recurrence have been seen.

The crucial role of gadolinium-enhanced MRI in a case of amaurosis fugax - a case report and literature review

Optic perineuritis is the inflammation of the optic nerve sheath. This affliction can lead to visual field impairment and other signs and symptoms related to the orbital space, such as pain, disc edema, ophthalmoplegia, proptosis. However, not all patients present with such suggestive symptoms, requiring a thorough assessment. We report the case of a young male admitted to our hospital for recurrent episodes of monocular blindness. Amaurosis fugax is a well-known presentation of transient ischemic attacks (TIA) and it was ruled out. Gadolinium-enhanced MRI revealed a typical aspect of optic perineuritis. It was mandatory to consider all possible causes of secondary optic perineuritis as they all represent serious clinical conditions, even if the idiopathic form is more frequent. The clinical and paraclinical evaluation of the patient excluded an underlying disease and primary optic perineuritis was diagnosed. Corticosteroid therapy is usually curative and a course of methylprednisolone was initiated for our patient with good outcome. However, response to treatment is not diagnostic as both primary and secondary optic perineuritis are normally responsive, hence thorough differential diagnosis is necessary.

Light After Darkness: A Case Report of Isolated Optic Perineuritis

This is a report on remarkable visual recovery from blindness in a case of isolated optic perineuritis (OPN). A 68-year-old Chinese lady presented with a two-week history of progressive painless bilateral vision loss. Her vision was 6/18 on the right eye and no perception of light (NPL) on the left eye with positive relative afferent pupillary defect (RAPD). Fundus showed hyperaemic and swollen optic disc bilaterally. MRI of the brain and orbit revealed hyperintense periventricular white matter lesions, possibly early changes of multiple sclerosis (MS), and perineural enhancement of optic nerve bilaterally, consistent with OPN. All other investigations were negative. Intravenous methylprednisolone 1g/day for three days was started, followed with oral prednisolone, tapered in three months. At the third month of follow-up, her vision had improved to 6/12 on the left and 6/9 on the right. The hyperaemic and swollen disc has resolved. Intravenous megadose corticosteroid treatment is an effective first-line treatment for OPN.

A Case Report of Bilateral Optic Perineuritis With Idiopathic Intracranial Hypertension: Challenges in Diagnosis and Management

Optic perineuritis (OPN) refers to the inflammation of the optic nerve sheath and it is a rare form of idiopathic orbital inflammatory disease. We report a rare case of bilateral OPN in an obese female teenager with idiopathic intracranial hypertension (IIH). She was initially presented with painless bilateral blurring of vision that was progressively worsening for three weeks duration. Visual acuity of both eyes was hand movement with no relative afferent pupillary defect detected. The confrontation visual field test showed central scotoma. Both anterior segments were unremarkable. Fundoscopy showed a swollen optic disc bilaterally, with extensive flame-shaped hemorrhages surrounding the disc area and dot blot hemorrhages in the posterior pole. A magnetic resonance imaging scan of the brain and orbit revealed the presence of bilateral optic nerve sheath enhancement with empty sella turcica. The patient was diagnosed with bilateral OPN with IIH. She received an initial high dose of systemic corticosteroid followed by a slow tapering dose. She was monitored by the neuromedical team for her IIH. She was followed up for about a year. The final best corrected visual acuity in the right eye was 6/36 and the left eye was 6/60. In conclusion, OPN poses challenges in diagnosis and management. This case emphasizes the importance of considering OPN in the differential diagnosis of optic nerve-related symptoms, as prompt recognition and intervention are crucial for favorable outcomes.

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.

Orbital MRI Findings in a Patient With Giant Cell Arteritis (GCA): A Case Report

Giant cell arteritis (GCA) is a medium- and large-vessel systemic vasculitis. It is common among people aged 50 years and older. GCA presents with cranial manifestations of headache, visual symptoms, cerebrovascular events, and systemic manifestations. The diagnosis of GCA is confirmed with a positive temporal artery biopsy. Treatment of GCA consists of high-dose steroids with slow tapering over 18 to 24 months and steroid-sparing therapy to maintain remission. Due to the risk of the most feared complication of GCA, irreversible visual loss, once GCA is suspected, high-dose steroids should be commenced immediately, and a temporal artery biopsy should be done not beyond one to two weeks after starting steroids to avoid the effects of steroids on the result of the temporal artery biopsy. There are orbital radiological findings reported in patients with an atypical presentation of GCA on MRI; these findings include non-specific orbital inflammation, optic nerve inflammation, optic nerve sheath inflammation, and optic chiasm enhancement.

Optic Perineuritis Associated With Cryptococcal Meningitis Presenting With a "Hot Orbit" in a Patient With Chronic Lymphocytic Leukemia

ABSTRACT

A 75-year-old man presented with 3 days of progressive left retro-orbital pain, eyelid swelling, tearing, and pain with extraocular movement. His medical history was significant for type II diabetes mellitus and chronic lymphocytic leukemia, stable on no therapy since diagnosis 8 years prior. The initial examination was significant for diffuse restriction of left ocular motility, marked lid edema, and mild dyschromatopsia. Computed tomography demonstrated asymmetric left periorbital soft tissue swelling and intraconal fat stranding with an irregular left optic nerve sheath complex and clear paranasal sinuses. He was hospitalized for orbital cellulitis and treated empirically with broad-spectrum intravenous antibiotics, but his visual acuity declined over the ensuing 2 days. Subsequent MRI demonstrated left-greater-than-right circumferential optic nerve sheath enhancement, and leptomeningeal enhancement. An orbital biopsy demonstrated monoclonal B-cell lymphocyte aggregation, whereas a lumbar puncture was positive for Cryptococcus antigen with subsequent demonstration of abundant Cryptococcus by Papanicolaou stain. The final diagnosis was optic perineuritis secondary to cryptococcal meningitis presenting with orbital inflammation. Although his clinical course was complicated by immune reconstitution inflammatory syndrome, symptoms and signs of optic neuropathy ultimately resolved after 1 month of intensive antifungal therapy.

Perineuritis or infiltration of optic nerve sheath? A presentation of diffuse large B cell Gastric lymphoma

Optic perineuritis is an inflammatory disorder involving the optic nerve sheath. It is currently considered as a part of idiopathic orbital inflammatory disease which also includes dacryoadenitis, orbital myositis, superior orbital fissure, and cavernous sinus syndrome (Tolosa hunt syndrome). As it is idiopathic, it is considered a diagnosis of exclusion. Another important differential is optic nerve lymphoma. Isolated optic nerve lymphoma associated with systemic involvement has been described in literature. We report a case that presented as third nerve palsy but later on developed central retinal vein occlusion and was ultimately diagnosed as primary gastric lymphoma of diffuse large B cell type.

Optic Perineuritis and Its Association With Autoimmune Diseases

Background: Optic perineuritis (OPN) is a special optic neuropathy that has a distinct etiology from neuromyelitis optica spectrum disorders (NMOSDs) or multiple sclerosis (MS)-related optic neuritis (ON). The mechanisms of how this inflammation developed and invaded the nerve sheath remain unknown. This study is aimed to analyze the etiology and different clinical characteristics of OPN in a Chinese patient population. Methods: Neuro-ophthalmological examination, orbit magnetic resonance imaging (MRI) and a series of blood samples were used in this retrospective observational cohort study to compare characteristics of OPN with idiopathic demyelination optic neuritis (IDON). Results: Forty-four OPN cases (74 eyes) and 61 IDON cases (78 eyes) were analyzed. OPN cases included 33 cases (59 eyes) were associated with specific autoimmune diseases, 10 cases (13 eyes) were associated with infection diseases, 1 case was idiopathic disease. The causes of OPN with CTD were Graves' disease, Immunoglobulin G4-related disease (IgG-4 RD), granulomatosis with polyangiitis (GAP), systemic lupus erythematosus (SLE), Sarcoidosis, Rheumatoid arthritis, scleroderma, Behcet's disease, and gout. All patients received orbital MRI. Overall, 33 cases showed orbit fat infiltration. Specifically, nine cases with IgG-4 RD showed trigeminal nerve branch involvement, 12 cases with Graves' disease showed extraocular muscle belly enlargement, and 4 cases with GAP showed pterygopalatine fossa pseudotumor. Compared to IDON patients, OPN patients were older (p = 0.004) and more likely bilateral involvement 26 (78.79%) patients had bilateral involvement in OPN group vs. 17 (27.87%) in the IDON group (p < 0.001). Visual acuity scores using LogMAR testing was better in OPN patients compared to those with IDON, 0.55 ± 0.91 vs. 1.19 ± 1.24 (p < 0.001). Other ophthalmologic findings unique to the OPN group include 11 (33.33%) cases of ptosis, nine (27.27%) cases of diplopia, and 10 (30.30%) cases of exophthalmos, compared to zero cases of these conditions in the IDON group. Eight (13.11%) IDON patients also had multiple sclerosis (MS) and 7 (11.48%) patients had neuromyelitis which was significantly more than the zero patients in OPN group (p = 0.04). Conclusions: OPN had distinct etiologies and clinical characteristics from IDON and is more often associated with autoimmune diseases. Using OPN characteristics to diagnose autoimmune diseases should prove useful for clinicians when presented with patients that have multiorgan dysfunction that include ophthalmologic findings.

An unusual presentation of neurosarcoidosis: Concurrent optic perineuritis and optic neuritis

Neurosarcoidosis is a rare complication of sarcoidosis and typically presents as acute cranial neuropathies. Neurosarcoidosis can rarely cause an inflammatory optic neuropathy, resembles an optic neuritis and even more rarely can cause an optic perineuritis. Although concomitant optic neuritis and optic perineuritis have been reported in other inflammatory conditions, such as myelin oligodendrocyte antibody-associated disease, spatially-distinct optic neuritis, and optic perineuritis has not been previously described in neurosarcoidosis. Here, we present a case of spatially-distinct concomitant optic neuritis and optic perineuritis from neurosarcoidosis in a 51-year-old man initially suspected to harbor metastatic disease based on imaging findings.

Incipient Syphilitic Papillitis

Patients with syphilis can present with optic disc oedema (ODE) without visual compromise, which has been primarily attributed to papilloedema from raised intracranial pressure or optic perineuritis from optic nerve sheath inflammation. We report four cases of ODE in the setting of syphilis with preserved visual function, normal intracranial pressure, and no enhancement of the optic nerve or sheath on magnetic resonance imaging. We propose the term "incipient syphilitic papillitis" for cases presenting with ODE, preserved vision and absence of optic nerve sheath enhancement, which is likely a more common presentation than syphilitic optic perineuritis.

Refractory optic perineuritis related to granulomatosis with polyangiitis treated with intensive immunosuppressive therapy combined with plasma exchange

Optic perineuritis (OPN), which is an inflammatory disorder affecting the optic nerve sheath, is one of the rare complications in granulomatosis with polyangiitis (GPA). Although several groups have reported that immunosuppressive therapies are generally effective against GPA-associated OPN, so far, there is little information as to other options for refractory cases. Here we demonstrate a case of GPA-associated OPN, which is refractory to potent immunosuppressive therapy including high-dose glucocorticoid, intravenous cyclophosphamide and rituximab therapy, and effective application of therapeutic plasma exchange. We also report here that CSF IL-6 levels may serve as a new biomarker for GPA-associated OPN.

Caecocentral Scotoma: A Rare Presentation of Optic Perineuritis

Optic perineuritis (OPN) is a subtype of optic neuritis (ON) in which the inflammatory process involves meningeal sheath surrounding the optic nerve. Clinically, OPN simulates ON. However, in contrast to ON, patient with OPN shows sparing of central vision, improves dramatically with high-dose corticosteroid, are more likely to experience recurrence after stopping treatment. We report a rare case of caecocentral scotoma observed in a female with typical ON symptoms. Her magnetic resonance imaging showed features in line with OPN. She was treated with intravenous methylprednisolone 1 g/day for five days followed by slow tapering dose of oral prednisolone for one month. Her vision improved dramatically with a resolution of visual field defect. No relapses seen within two years of follow-up.

Critical review: Typical and atypical optic neuritis

Typical optic neuritis is an idiopathic demyelinating condition that is often associated with multiple sclerosis. This has been well characterized and has an excellent prognosis. Atypical optic neuritis can result from an inflammatory, infectious, or autoimmune disorder. Differentiating the two types of optic neuritis is paramount and may be challenging early on in the clinical course. This review describes the recent literature describing the pathophysiology, clinical presentation, neuroimaging, and management of these disorders.

Optic Perineuritis in Neuromyelitis Optica Spectrum Disorder

Optic perineuritis (OPN) involvement in demyelinating disease is rarely encountered. To our knowledge, this is the first reported case of bilateral OPN associated with neuromyelitis optica spectrum disorder (NMOSD). We present a case of a healthy young gentleman who presented with OPN, initially presumed to have a young stroke but later diagnosed to be NMOSD. Early neuroimaging is essential to help distinguish optic neuritis (ON), and prolonged treatment of systemic immunosuppression is the mainstay of treatment.

Uveitis and optic perineuritis in the context of myelin oligodendrocyte glycoprotein antibody seropositivity

BACKGROUND AND PURPOSE

Antibodies to myelin oligodendrocyte glycoprotein (MOG) have been identified in both children and adults with demyelination, with a strong association with bilateral or recurrent optic neuritis (ON). However, the full clinical spectrum of this newly described condition is unknown. We sought to describe non-ON inflammatory ophthalmological presentations such as uveitis and optic perineuritis in the context of MOG antibody seropositivity.

METHODS

Using a live cell-based assay analysed by flow cytometry, we identified seropositive patients referred for MOG antibody testing in Australasia between 2014 and 2017. We identified four MOG antibody-positive patients with non-ON inflammatory ophthalmological presentations and present their detailed clinical information in this case series.

RESULTS

Three patients had uveitis either in association with, or remote from, ON. One patient had optic perineuritis and peripheral ulcerative keratitis. We describe the presentation, examination, investigation findings and clinical course of these four patients.

CONCLUSIONS

Recognition of these novel clinical associations may expand the clinical spectrum of MOG antibody-associated presentations. An expedited diagnosis may guide the management of these complex patients.

Colon cancer and IgG4-related disease with orbital inflammation and bilateral optic perineuritis: A case report

RATIONALE

Immunoglobulin G4-related disease (IgG4-RD) is an inflammatory condition of unknown cause. Cancer might be related to the development of certain IgG4-RD but to date, little literature documents it.

PATIENT CONCERNS

A 78-year old man presented with unilateral proptosis responsive to steroids, initially attributed to nonspecific orbital inflammation.

DIAGNOSIS

Right hemicolectomy was performed because of a suspicious lesion which turned out to be tubulovillous adenoma on histological analysis. Eight months after the surgery, a mass infiltrating the mesentery was found and biopsy revealed IgG4-RD.

INTERVENTIONS

Both the orbital inflammation and abdominal mass infiltrating the mesentery were responsive to steroids and rituximab administered to treat IgG4-RD.

OUTCOMES

In the course of IgG4-RD, the patient developed bilateral optic perineuritis, causing bilateral visual loss. Colon cancer with synchronous multiple liver metastases was found 1 year after rituximab treatment.

LESSONS

This case raises the possibility of IgG4-RD being a paraneoplastic syndrome in some patients. Cancer screening should probably be performed in some elderly patients diagnosed with IgG4-RD.

[A case of optic perineuritis-A literature review of Japanese cases and clinical problems]

A 64-year-old woman was admitted to our hospital owing to decreased visual acuity and visual field defect. She had a similar history of decreased visual acuity and received steroid therapy 10 years ago. Brain MRI revealed gadolinium-enhancement in the sheath of the optic nerve, called "tram-track" and "doughnut" signs. Optic perineuritis (OPN) was diagnosed on the basis of her clinical manifestations, which improved on treatment with high-dose methylprednisolone (mPSL). However, clinical manifestations relapsed 10 days post-discharge; hence, she was re-admitted. She was re-administered high-dose mPSL and subsequent oral administration of prednisolone. She had no relapse or recurrence for the last 2 years. We reviewed studies involving Japanese patients with OPN, including 17 idiopathic and 14 secondary cases and found that 43% of patients had recurrences and 30% of patients had poor outcome including severe residuals of visual acuity. Secondary OPN occurred owing to various diseases manifesting generalized systematic inflammation. Timely and suitable treatment was very important for clinical favorable outcomes in OPN.

Metastatic Melanoma of the Optic Nerve Sheath

A 23-year-old man with a history of metastatic melanoma developed painful vision loss to counting fingers with enhancement of optic nerve on contrast-enhanced magnetic resonance imaging (MRI) and received a diagnosis of optic neuritis from an outside hospital. Despite empiric corticosteroid therapy, the patient worsened and developed secondary central retinal vein occlusion with further deterioration of vision. Repeat MRI demonstrated optic nerve sheath (ONS) involvement suggestive of optic perineuritis (OPN) and an ONS biopsy confirmed a rare case of isolated metastatic melanoma. Our case highlights the clinical and radiographic features that can mimic OPN and delay diagnosis and treatment.

Refractory optic perineuritis due to granulomatosis with polyangiitis successfully treated with methotrexate and mycophenolate mofetil combination therapy

Optic perineuritis is an uncommon inflammatory disorder of the optic sheath that causes visual loss or eye pain. There are few case reports of optic perineuritis associated with granulomatosis with polyangiitis. Herein we report the case of a 37-year-old male with granulomatosis with polyangiitis and who presented with headache, blurred vision in the right eye, diplopia, and numbness in the right forehead. Brain magnetic resonance images (MRI) findings revealed hypertrophic pachymeningitis and refractory optic perineuritis. These were manageable only by means of weekly methotrexate and mycophenolate mofetil combination therapy but not with methotrexate, mycophenolate mofetil, intravenous cyclophosphamide, rituximab, azathioprine, or cyclosporine individually.

Latent orbital pseudotumor secondary to systemic lupus erythematosus

Orbital inflammatory pseudotumor is a rare complication of systemic lupus erythematosus. It may present a challenge for differential diagnosis, especially in the context of treatment with hydroxychloroquine, although dosage and duration of the treatment may guide us. Although high antibody titers can be found, this is not specific.

Evaluation of Retinal Nerve Fiber Layer in Patients with Idiopathic Optic Perineuritis using Optical Coherence Tomography

The aim of this study was to assess the effect of idiopathic Optic perineuritis on the retinal nerve fiber layer, and determine the ability of optical coherence tomography to evaluate retinal nerve fiber loss after idiopathic Optic perineuritis. Four patients were assessed in this study. In all cases, average retinal nerve fiber layer was significantly thinner in the affected eye in comparison with the normal reference value and with the value for the contralateral normal eye at 12 months after the onset of optic perineuritis. Our study revealed that retinal nerve fiber layer loss occurs in idiopathic optic nerve sheath inflammation.

Recurrent Optic Perineuritis after Intranasal Cocaine Abuse

Recurrent optic perineuritis can be related to orbital inflammation. Here we present the case of a 46-year-old male patient in whom recurrent episodes of optic perineuritis were related to chronic osteolytic sinusitis following intranasal cocaine abuse. Magnetic resonance imaging (MRI) demonstrated optic perineuritis adjacent to a soft tissue mass that intruded the orbit from the nasal cavity. Computed tomography (CT) confirmed destruction of the medial orbital wall. Staphylococcus aureus was cultured and biopsy showed granulomatous tissue. Visual outcome was poor. We review the literature and discuss the diagnostic pitfalls and management implications in relation to optic (peri)neuritis originating from the nasal sinuses.