eMedicine Specialties > Ophthalmology > Optic Nerve

Optic Neuropathy, Compressive: Differential Diagnoses & Workup

Author: Talmadge (Ted) Cooper, MD, Adjunct Clinical Associate Professor, Department of Ophthalmology, Stanford Medical School
Contributor Information and Disclosures

Updated: Sep 10, 2007

Differential Diagnoses

Dermoid, Orbital
Meningioma, Optic Nerve Sheath
Hemangioma, Capillary
Meningioma, Sphenoid Wing
Hemangioma, Cavernous
Sarcoidosis
Leukemias
Thyroid Ophthalmopathy

Other Problems to Be Considered

Schwannoma
Pituitary adenoma
Craniopharyngioma
Lymphoma
Aneurysms
Fibrous dysplasia
Orbital hemorrhage
Mucocele
Orbital pseudotumor
Metastatic carcinoma
Carcinomas extending from sinuses

Workup

Laboratory Studies

  • Blood tests are sometimes helpful in the diagnosis of compressive optic neuropathy.
    • If thyroid ophthalmopathy is suspected, blood tests for thyroid function and anti-thyroid antibodies should be performed.
    • An elevated angiotensin-converting enzyme may be seen in sarcoidosis.
    • An elevated prostate specific antigen (PSA) may be helpful in male patients with suspected bony orbital metastases and optic nerve compression.

Imaging Studies

  • CT scans and MRIs are the foundation for determining the cause of optic nerve compression. CT scans better illustrate bony detail, and MRIs better delineate soft tissue lesions. The two imaging studies often offer complementary information. Interpretation of both the axial view and the coronal view and, occasionally, sagittal projections is required. MRI of the orbit should be ordered with gadolinium and fat suppression.
  • MRIs and CT scans are essential in evaluating cases of compressive optic neuropathy.
    • In addition to revealing the extent and location of the lesion, the imaging characteristics of the lesion will probably permit an experienced neuroradiologist to differentiate between optic nerve sheath meningiomas and optic nerve gliomas. Optic nerve sheath meningiomas will show "tram tracking" on axial views and a "target sign" on coronal views. Optic nerve glioma may show kinking, especially on sagittal views. On axial views, fusiform enlargement of the nerve is present. On coronal views, gliomas may show diffuse enhancement.
    • A characteristic pattern of enlargement of the extraocular muscles is found in thyroid ophthalmopathy.
  • Occasionally, ocular ultrasound is helpful. Orbital ultrasound may be useful in lesions affecting the portion of the optic nerve near the globe, but such cases also should undergo either MRI or CT scan.
  • In the modern era of neuroimaging, plain x-ray studies play little role in the evaluation of suspected optic nerve compression. Findings, such as asymmetric enlargement of the optic foramen or hyperostosis of the optic nerve canal, require further workup with CT scan and MRI.

More on Optic Neuropathy, Compressive

Overview: Optic Neuropathy, Compressive
Differential Diagnoses & Workup: Optic Neuropathy, Compressive
Treatment & Medication: Optic Neuropathy, Compressive
Follow-up: Optic Neuropathy, Compressive
Multimedia: Optic Neuropathy, Compressive
References
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References

  1. Lee AG, Chau FY, Golnik KC, Kardon RH, Wall M. The diagnostic yield of the evaluation for isolated unexplained optic atrophy. Ophthalmology. May 2005;112(5):757-9. [Medline].

  2. Miller NR, Newman NJ, Biousse V. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 6th ed. Lippincott, Williams & Wilkins; 2004.

  3. Schiefer U, Wilhelm H, Hart, W. Neuro-ophthalmic presentations of orbital disease. In: Clinical Neuro-Ophthalmology: A Practical Guide. Wien & New York: Springer; 2007.

  4. Shields AJ, Shields CL, Scartozzi R. Survey of 1264 patients with orbital tumors and simulating lesions: the 2002 Montgomery Lecture, Part 1. Ophthalmology. 2004;111(5):997-1008. [Medline].

  5. Spoor, TC. Atlas of Oculoplastic and Orbital Surgery. Informa Healthcare; 2007.

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Further Reading

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Keywords

compressive optic neuropathy, optic neuropathies, optic neuritis, optic nerve, optic nerve compression, optic atrophy, vision loss, thyroid ophthalmopathy

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Contributor Information and Disclosures

Author

Talmadge (Ted) Cooper, MD, Adjunct Clinical Associate Professor, Department of Ophthalmology, Stanford Medical School
Talmadge (Ted) Cooper, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Medical Informatics
Disclosure: Nothing to disclose.

Medical Editor

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto, Sunnybrook and Women's Health Sciences Center, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Canadian Medical Association, Canadian Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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