demyelinating optic neuritis last - cybersight.org · papillitis 35% retrobulbar neuritis 65%...
TRANSCRIPT
Demyelinating Optic Neuritis
Bayasgalan Purevdorj, MD, FICO, MMEdDepartment of Ophthalmology
Mongolian National University of Medical Sciences18th Dec 2018
Acknowledgement Cybersight/ ORBIS
Mongolian Ophthalmologists’ Society
Mongolian National University of Medical Sciences
Karl Golnik, MD
Oculoplastic Clinic
Судалгаа авч үзье!●Нүдний эмч - 1 ●Резидент эмч - 2 ●Мэдрэлийн эмч - 3●Оюутан - 4●Бусад- 5
Асуулт-1 ● Харааны мэдрэлийн миелингүйжих үрэвсэл
ихэвчлэн өндөр настай хүмүүс тохиолддог.
1. Үнэн2. Худал
Асуулт-2 ● Харааны мэдрэлийн миелингүйжих үрэвслийн үед
хараа сэргэх тавилан ерөнхийдөө муу байдаг.
1. Үнэн2. Худал
Асуулт-3● Харааны мэдрэлийн миелингүйжих үрэвслийн
дахих эрсдэл үйлчлүүлэгчид преднизолон схемээр уулгасан тохиолдолд буурдаг.
1. Үнэн 2. Худал
Асуулт-4● Харааны мэдрэлийн миелингүйжих үрэвслийн
дараа тархмал хатуурал өвчин үүсэх эрсдэл MRI шинжилгээнд өөрчлөлтгүй тохиолдолд буурдаг.
1. Үнэн 2. Худал
Subjects in the Optic Neuritis Treatment Trial, who
were enrolled between July 1, 1988, and June 30,
1991, were followed up prospectively for 15 years,
with the final examination in 2006.
Optic neuritis (ON)
● Inflammation of the optic nerve● Anterior optic neuritis- swollen optic disc “papillitis”
● Retrobulbar optic neuritis
● Highly associated with multiple sclerosis (MS)
● 15 -20 % MS presenting feature
Optic nerve● CN II● Part of CNS not peripheral nerve● Myelinated axons of the retinal ganglion cells (RGC) ● Interspersed with connective tissue septae● Approximately 800,000 to 1.5 million nerve fibers● End at Lateral geniculate nucleus (LGN)● 50 mm in length posterior scleraà optic chiasm
The 4 portions of the optic nerve. The lengths are given. (From Sadun AA: Anatomy and physiology. In Yanoff M, Duker JS [eds]: Ophthalmology, 2nd ed, St. Louis, Mosby, 2004.)
Elsevier items and derived items © 2005 by Elsevier Inc.
1. Intraocular
2.Intraobital
4 portions
3. Intracanalicular
4.Intracranial
Myelin of optic nerve
● Provided by Oligodendrocytes● Normally absent in the retina
and optic nerve head● First appearing posterior to the lamina cribrosa ● Provide the myelin sheath to RGC axons.
Intraocular portion
Role of myelin ● Physiologic properties
▪ ↑ resistance ; less leakage▪ ↓ capacitance of the axon ; less Na+ are needed
● ↓ amount of ionic are needed to change membrane potential
● Ionic homeostasis
Saltatory conduction
Pathophysiology
PathophysiologyInflammatory demyelination of the optic nerve
Genetic● Controversy● Histocompatibility antigens HLA-A3, HLA-A7, and
HLA-LD-a have been reported to be increased in optic neuritis and MS.
● In other studies, no significant differences were found in HLA distribution
Epidemiology● 2/3 woman● 18-50 years average 32 year● Annual incidence 2.2-6.4 per 100,000 in the united
stated● occurs more frequently in whites than blacks and
Asian● Incidence ON related with MS
Epidimiology
Clinical Features&Diagnosis●**Clinical diagnosis**● Classic triad of optic neuritis
1 Loss of vision2 Periocular pain3 Dyschromatopsia
● Visual disfunction● Asymptomatic+optic nerve dysfunction
Clinical symptoms
Loss of vision● Most common and important● > 90% diffuse loss of vision ● Within● Hour - 29% ● 1-2 days – 20%● 3-7 days – 23%● 1-2 wks – 7%
● Progressive visual loss 7-10 days then stable● Mild visual loss – no PL
Periocular pain● > 90%● Eye movement● Preceding or coinciding with visual loss
● Central visual loss● 24-36 hrs most severe● Improve within 48-72 hrs● Cause : Theory
● Optic nerve sheaths --> Small branches of trigeminal N.● Inf lammation of optic N. in orbital apex ;extraocular m.sheath
fused nerve sheaths ● Retrobulbar optic neuritis > Papillitis
Dyschromatopsia /1/● Color vision defect ● 94%● Desaturation of colour● Out of proportion with VA
● Farnsworth-Munsell 100 Hue Test● More sensitivity 94%
Dyschromatopsia /2/
Phosphenes● lashes of light induced by eye movement or sound● Preceding or coinciding with visual loss● Same eye
Uhthoff’s phenomenon● 50% after ON● Significant related ● Abnormal MRI brainàrisk MS● Recurrent ON
● Aggrevated by ● Exercise● Heat● Sress
Pulfrich phenomenon● Motion of pendulum appears elliptical due to altered
depth perception from delayed conduction in the demyelinated nerve
Clinical signs
Visual acuity● Initial and Follow-up visual acuity (VA) in Patients with Acute Isolated
Optic Neuritis in the Optic Neuritis Treatment Trial (ONTT)
Acuity Initial 1 year 10 years 15 years
20/40 or better 35 % 93% 92% 92%
20/50-20/190 29 % 4% 5% 5%
20/200 – NLP 36 % 3% 3% 3%
NLP= no light perception
Visual field defect● Nerve fiber bundle
related VF defect● Recommend VF baseline
for follow up● In ONTT :
Central field > peripheral ● Focal defect (42%) :
Arcuate , Altitudinal , Nasal
Clinical signs● Pupillary reaction● Pupillary light reflex à
↓ abnormal eye● RAPD positive
papillitis
35%
retrobulbar neuritis
65%
Opthalmoscopic appearance
CMV may cause an “isolated” papillitis, check the periphery!
Neuroretinitis - disc swelling and macular star of exudate.
cat scratch disease, idiopathic, toxoplasmosis, syphillis
NOT MS!
Unusual ocular findings
●Marked anterior and/or posterior segment inflammation
●Marked periphlebitis (venous sheathing)●Markedly swollen optic nerve head●Marked optic disc haemorrhages●Macular star
Investigations● Neuroimaging● CT scan● MRI
● VEPs● CSF analysis
MRI scan● Sensitivity > CT scan● A magnetic resonance imaging study (MRI) of the brain
and orbits with gadolinium contrast provides ● confirmation of the diagnosis of acute demyelinating optic
neuritis ● important prognostic information àrisk of developing MS.
● Fat-suppression techniques and godolinium infusion-Best visualized lesions in the optic nerves of patients with symptomatic optic neuritis
MRI use in ● Atypical optic neuritis ● confirm diagnosis● find cause
● Typical optic neuritis● Prognostic indicator for future MS
MRI: Nerve Sheath Enhancement
●
MRI in MS● Neuroimaging study of choice for MS; MRI scan with● FLAIR –Fluid-attenuated inversion recovery sequencing● Godolinium infusion
● Superior to CT scan àposterior fossa and spinal cord
● 85% -95% àMultiple lesions with CDMS● Most common lesions :Periventricular ,ovoid and
multifocal lesions
MRI in MS● T1 scans with contrast.● Active new lesions àenhance with gadolinium-DPTA administration
MRI in MS● T2/FLAIR● Show the total amount of
lesion from MS from its onset.
● The pictures show both old and new inflammation.
VEP (visual evoked potential)
VEP● visual evoked potential● axonal demyelination● slowed conduction in the optic nerve● Latency is prolonged ; delay in the P100● Amplitude may be only mildly reduced● A normal VEP is sensitive in excluding a lesion of the
optic nerve, along its pathways in the anterior part of visual pathway
● Useful distinguish functional visual loss
Харааны дуудлагат потенциалын шинжилгээ
Optical coherence tomography● Optical coherence tomography (OCT)
● Measures the thickness in the retinal NFL
● Most of RNFL loss occurred between 3-6 months 85 % pts
● In one study, OCT was less sensitive than VER in detecting
subclinical optic neuritis .
● A number of studies have found that a greater severity of optic
nerve injury seen on OCT suggests neuromyelitis optica (NMO)
rather than optic neuritis associated with multiple sclerosis .
Clinical Features /1/Features of typical demyelinating ON in adults
● Acute to subacute onset – progressive over a few days to 2 weeks
● Young adult patient, typically < 45 years of age, but may be of any age
● Periocular pain (90%), especially with eye movement
– preceding or coinciding with visual loss
● Unilateral loss of visual acuity – variable severity
● Reduced contrast and colour vision – out of proportion to loss of VA
Clinical Features /2/● Uhthoff’s phenomenon● Ipsilateral RAPD● Normal (65%) or swollen (35%) optic nerve head● Mild periphlebitis (venous sheathing)● VF defect – almost any type● Spontaneous visual improvement in >90% starting within
2–3 weeks regardless of treatment● No deterioration in vision when corticosteroids are
withdrawn
Clinical Features /3/● optic disc pallor is seen within 4–6 weeks from onset
of visual loss● Overall, 50% of clinically isolated cases of ON go on to
develop a second MS-defining episode by 15 years.● The risk of developing MS is ● 25% when baseline MRI is normal and ● 75% when MRI has one or more brain lesions typical for
MS● Ancillary investigations suggestive of MS
MRI in MS● T2/FLAIR● Show the total amount of
lesion from MS from its onset.
● The pictures show both old and new inflammation.
Cumulative Probability of CDMSby Number of Brain MRI Lesions
0.
15.
30.
45.
60.
0. 1. 2. 3. 4. 5.
% C
DM
S
Year
16% No lesions
37% 1-2 lesions
51% > 3 lesions
Residual Visual defects after Resolution of ON
● VA 15 – 30 %● Contrast sensitivity 63-100 %● Color vision 33- 100 %● Visual field 62 – 100 %● Steropsis 89%● Light bright sense 89-100%● Pupillary reaction to light 55 -92 %● Optic disc appearance 60 – 80% ● VEP 63 -100 %
Differential diagnosisDifferential diagnosis of Optic Neuritis
● Corticosteroid-responsive optic neuropathiesSarcoidosis, systemic lupus erythematosus, Behçet Syndrome,
autoimmune ON, NMO, chronic relapsing inflammatory optic neuropathy●Other inflammatory conditions
Post-infection, post-vaccination, neuroretinitis, acute disseminated encephalomyelitis
● Compressive optic neuropathiesPrimary tumours, gliomas, meningioma, pituitary tumours – particularly craniopharyngioma in children, metastases, sinus mucocoeles, arterial
aneurysms● Ischaemic optic neuropathies
Anterior and posterior ischaemic optic neuropathy,giant cell arteritis, diabetic papillopathy
Differential diagnosis● Infective conditions
Tuberculosis, syphilis, Lyme disease, viral ON,toxocariasis or helminthitis (usually visible retinal/optic head lesion)
● Toxic and nutritional optic neuropathyVitamin B12 deficiency, tobacco-ethanol amblyopia,methanol intoxication, ethambutol toxicity
● Inherited conditionsLeber hereditary optic neuropathy
● Ocular causesPosterior scleritis, maculopathy, retinopathy, big blind spot syndrome
● Periorbital infectionCellulitis, severe suppurative sinusitis
● Factitious visual lossIntentional or ‘hysterical’
Overlap of Optic Neuritis & Anterior Ischemic Optic Neuropathy (AION)
Optic neuritis AIONDermographicsMean age ,yrs(range)Gender, % femaleRace, % CaucasianAnnual incidence,per 100000
33 (5-70)70%85%2-6
66 (11-90)45%95%1-6
SymptomsPainProgression for daysImprovement
92%70%>90%
10%30-45%>40%
SignAcuityField defect(most common)
Disc edema
20/15 – NLPCentral scotoma,generalized depression
35%
20/15 – NLPNerve fiber bundle(inferior altitudinal)
100%
Neuromyelitis optica ● Diagnosis criteria (99% sensitivity,94% specificity)
● Optic neuritis (unilateral or bilateral)
● Acute myelitis● Plus at least 2 of the following:
● a contiguous spinal cord lesion on MRI involving 3 vertebral segments or more
● a brain MRI nondiagnostic for MS● a positive NMO-IgG serologic
test
● The Arrow indicates spinal cord inflammation in NMO.
Acute Therapeutic options for Optic neuritis
Recommended regimen● 1 g IV Methylprednisolone sodium succinate/day x 3
days● 1 mg/kg qd for 11 days, followed by a four-day taper● An oral taper, however, is not normally necessary as this short
treatment is unlikely to suppress the hypothalamic-pituitary axis.● Review within 1 month is recommended to ensure that vision does
not deteriorate after cessation of treatment.● Appropriate consent should be taken prior to commencing
corticosteroids.
Acute Therapeutic options for Optic neuritis
● High-dose intravenous corticosteroids were effective in improving short-term visual recovery
● no statistically significant benefit in long-term outcome ● Corticosteroids do cause side-effects
● minor such as insomnia, weight gain and mood alterations● major including psychotic depression, pancreatitis and
osteonecrosis
Acute Therapeutic options for Optic neuritis
● Corticosteroids are considered for patients who require faster recovery such as ● monocular patients● patients with severe bilateral visual loss● those with occupations requiring normal visual acuity
Risk of recurrence of Optic neuritis● In the ONTT, Recurrence 28% à 5 yrs
35%à 10 yrs● More common in patients with MS ● Oral prednisolone alone is not recommended● no benefit ● associated with an increased recurrence rate double
than of the other groups
Probability of Recurrent Optic Neuritis in Either Eye by Treatment Group
0.
12.5
25.
37.5
50.
0. 1. 2. 3. 4. 5.
% w
ith fi
rst r
ecur
renc
e
Year
41% Oral Prednisone
25% Placebo
25% Intravenous
P=0.004 Prednisone vs PlaceboP=0.003 Prednisone vs Intravenous
Neuromyelitis optica (NMO)● Prognosis-Both visual and neurologic prognosis in
NMO are poorer than in MS● Episodes of visual loss are recurrent● Severe visual impairment (<20/200) common in at
least 1 eye ● Treatment not been well studied● Immunosuppressive agents remain the mainstay of
therapy for acute episodes● IV Methylprednisolone 1 g/day x 5 d then oral pred
Immunomodulatory therapy● Immunodulatory agents; disease-modifying agents
Immunodulatory agents● Interferon beta 1b (Betaseron)● Interferon beta 1a subcutaneous(Rebif)● Interferon beta 1a intramuscular(Avonex)● Glatiramer acetate (Copaxone)● Tysabri (natalizumab)
Randomised,double masked,placebo-controlled trials
● The Controlled High-Risk Subjects Avonex Multiple Sclerosis Prevention Study (CHAMPS)
● The Early Treatment of Multiple Sclerosis trial (ETOMS)
● The Betaferon in Newly Emerging Multiple Sclerosis for Initial Treatment trial (BENEFIT)
● Reduce MS exacerbations ~ 1/3● Time interval between first and secondary relapses● Fewer lesions on brain MRI● Current research suggests early diagnosis and therapy are
advantage
Optic neuritis in children● 50 – 75% Bilateral vision loss● Swelling of optic nerves● IV Methylprednisolone 1-4 mg/kg/day 3-5 days then ● Oral prednisolone 1 mg/kg/day tape off 4 wks● Low risk of MS● > 80% good visual prognosis
Асуулт-1 ● Харааны мэдрэлийн миелингүйжих үрэвсэл
ихэвчлэн өндөр настай хүмүүс тохиолддог.
1. Үнэн2. Худал
Асуулт-2 ● Харааны мэдрэлийн миелингүйжих үрэвслийн үед
хараа сэргэх тавилан ерөнхийдөө муу байдаг.
1. Үнэн2. Худал
Асуулт-3● Харааны мэдрэлийн миелингүйжих үрэвслийн
дахих эрсдэл үйлчлүүлэгчид преднизолон схемээр уулгасан тохиолдолд буурдаг.
1. Үнэн 2. Худал
Асуулт-4● Харааны мэдрэлийн миелингүйжих үрэвслийн
дараа тархмал хатуурал өвчин үүсэх эрсдэл MRI шинжилгээнд өөрчлөлтгүй тохиолдолд буурдаг.
1. Үнэн 2. Худал
Subjects in the Optic Neuritis Treatment Trial, who were enrolled between July 1, 1988, and June 30, 1991, were followed up prospectively for 15 years, with the final examination in 2006.
The Optic Neuritis Treatment Trial (ONTT)● Objective: to evaluate the role of corticosteroids in the
treatment of unilateral optic neuritis
● Inclusion criteria: unilateral optic neuritis
Brain MRI in the Diagnosis of Multiple Sclerosis*Dissemination in Space $ Dissemination in Time- One or more gadolinium enhancing lesions#or nine hyperintense white matter lesions on T2 weighted MRI (if no enhancing lesion present)- One or more infratentorial lesion- One or more juxtacortical lesions- Three or more periventricular lesions- A spinal cord lesion can substitute for one infratentorial brain lesion
Gadolinium enhancing lesion > 3 months after initial clinical event
New T2 lesion at any time > 30 days after the baseline brain MRI
*Revised Mcdonald Criteria172$ Need to fulfill at least 3 of these criteria# lesions should be 3 or more millimeters
The ONTT: Methods● Randomization to one of 3 groups
1. IV steroids: 250 mg methylprednisolone qid x 3 days, oral prednisone (1mg/kg) x 11 days
2. Oral steroids: prednisone 1mg/kg/day x 14 days
3. Oral placebo: 14 days
Update Diagnosis Criteria for MS. The Diagnosis of Multiple Sclerosis Depends upon Dissemination in Time(Attacks Seperated by at Least One month) and Space. Evidence of dissemination can be Determined by Clinical Examination,MRI,and/or Lumbar Puncture
#Attacks* #Attack with Objective Clinical Evidence
Proof Required for Dissemination inTime
Proof Required for Dissemination in Space
≥ 2 ≥ 2 None None
≥ 2 1 None MRI or 2+ MRI lesions and abnl CSF or second attack
1 ≥ 2 MRI or second attack None
1 1 MRI or second attack MRI or 2+ MRI lesions and abnl CSF or second attack
Insidious neurological progression suggestive of MS :
abnl CSF + Dissemination in time demonstrated by MRI +
a) ≥9 T2 MRI lesions or≥2 spinal cord lesions or 4–8 brain MRI lesions + 1 spinal cord lesion
ora) Abnormal VEP‡ + [≥4 brain MRI lesions or <4 MRI lesions + 1 spinal cord lesion]
Clinical FeaturesFeatures of atypical ON in adults ● Age >50 or <12 years● Bilateral simultaneous or rapidly sequential ON and
chiasmitis● Severe visual loss – no light perception● Progressive visual loss for >2 weeks from onset● Painless visual loss● Pain following onset of visual loss or persistent pain for
>2 weeks from onset
Clinical Features● Severe pain that restricts eye movements or wakes
patient from sleep● Unusual ocular findings:
● Marked anterior and/or posterior segment inflammation● Marked periphlebitis (venous sheathing)● Markedly swollen optic nerve head● Marked optic disc haemorrhages● Macular star
● Lack of any visual recovery within 5 weeks or continued deterioration in visual function
Clinical Features● Symptoms or signs of a systemic disorder other than MS● African or Asian race● Family history● Corticosteroid-dependent optic neuropathy/deterioration
in vision when corticosteroids are withdrawn● Previous history of neoplasia● Ancillary investigations suggestive of a diagnosis
other than MS (NMO, sarcoidosis, Behçet syndrome
Feature NMO MS
Clinical involvement beyond the spinal cord and optic nerves
Rarely Usually
Attacks are bilateral Usually Rarely
Oligoclonal bands in spinal fluid
Rarely Frequently
White matter lesions on brain MRI
Rarely and usually resolvingUsually
Transverse myelitis as presentation
In 20% of cases Rarely
Swelling and signal change on MRI
Often Less often than NMO
Tissue destruction and cavitation
More than MS Less than NMO
Protein content in cerebrospinal fluid
Higher than MS Lower than NMO