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Compressive Optic Neuropathy Workup

  • Author: Jonathan W Kim, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Nov 16, 2015
 

Laboratory Studies

Blood tests are sometimes helpful in the diagnosis of compressive optic neuropathy. However, the serologic workup should be guided by the history and clinical presentation.[6]

If thyroid ophthalmopathy is suspected, blood tests for thyroid function and anti-thyroid antibodies should be performed.

An elevated angiotensin-converting enzyme level may be seen in 52%-90% of patients with active sarcoidosis.[7]

An elevated prostate specific antigen (PSA) level may be helpful in male patients with suspected bony orbital metastases and optic nerve compression.

Insulin-like growth factor 1 (IGF-1), prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyrotropin-releasing hormone (TRH) and alpha subunit, cortisol, and thyroxine (T4) can be obtained to assess a pituitary tumor. 

Alkaline phosphatase levels would be elevated in Paget disease of bone; an elevated bone-specific alkaline phosphatase (BSAP) has 84% sensitivity.[8]  

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Imaging Studies

Whenever there is clinical suspicion of compressive optic neuropathy (CON), a neuroimaging study is mandatory to determine the presence and location of the responsible lesion. With the sensitivity and specificity of modern neuroimaging, a negative scan essentially rules out the possibility of CON as the cause of vision loss.

In most cases of CON, magnetic resonance imaging (MRI) is the imaging modality of choice because of the excellent soft-tissue resolution of the anterior visual pathway and parasellar area; typically an orbit and brain MRI with and without contrast is ordered to evaluate a patient for CON.Abnormalities within the peri-optical spaces are more consistent with meningiomas, whereas a global increase in the size of the optic nerve is in favor of a glioma. Example MRIs are shown below.

Axial MRI taken 3 weeks after the onset of distort Axial MRI taken 3 weeks after the onset of distorted vision in the right eye; visual acuity is reduced to counting fingers at 1 ft. Evidence of optic nerve compression is not seen; disease in the sphenoid sinus is reported.
MRI of same patient as in the image above taken 4 MRI of same patient as in the image above taken 4 months later. Patient responded well to IV Solu-Medrol, but symptoms returned when steroids were reduced. Large mass compressing the right optic nerve is seen. Biopsy revealed lymphoma.
Neuroimaging study (MRI of brain and orbits) revea Neuroimaging study (MRI of brain and orbits) revealed an extensive meningioma involving the left orbital apex (arrow).

Computed tomography (CT) scanning offers excellent visualization of the bony anatomy and is particularly useful to evaluate the intraconal space of the orbit. However, for imaging the orbital apex and optic canal, MRI is preferred over CT due to the absence of signal interference from adjacent bone seen on tomography. 

Ultrasonography may be useful to document the presence of anterior orbital lesions but offers limited penetration into the deep orbit. However, in certain clinical situations, ultrasonography may be used to image patients quickly in the office in order to determine whether CT or MRI is warranted.

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Contributor Information and Disclosures
Author

Jonathan W Kim, MD Director of Oculoplastic and Orbital Surgery, Co-director of Ocular Oncology Service, Co-director of Neuro-ophthalmology Service, Department of Ophthalmology, Stanford Medical Center

Jonathan W Kim, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Talmadge (Ted) Cooper, MD Clinical Associate Professor, Department of Ophthalmology, Stanford University School of Medicine

Talmadge (Ted) Cooper, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Medical Informatics

Disclosure: Nothing to disclose.

Diana Katherine Lee Georgetown University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

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

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

  3. Bulters DO, Shenouda E, Evans BT, Mathad N, Lang DA. Visual recovery following optic nerve decompression for chronic compressive neuropathy. Acta Neurochir (Wien). 2009 Apr. 151(4):325-34. [Medline].

  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. Hodson KE, Bowman RJ, Mafwiri M, et al. Low folate status and indoor pollution are risk factors for endemic optic neuropathy in Tanzania. Br J Ophthalmol. 2011 Oct. 95(10):1361-4. [Medline].

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

  7. Thomas KW, Hunninghake GW. Sarcoidosis. JAMA. 2003 Jun 25. 289 (24):3300-3. [Medline].

  8. Alvarez L, Guañabens N, Peris P, Monegal A, Bedini JL, Deulofeu R, et al. Discriminative value of biochemical markers of bone turnover in assessing the activity of Paget's disease. J Bone Miner Res. 1995 Mar. 10 (3):458-65. [Medline].

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

  10. Phillips ME, Marzban MM, Kathuria SS. Treatment of thyroid eye disease. Curr Treat Options Neurol. 2010 Jan. 12 (1):64-9. [Medline].

  11. Verity DH, Rose GE. Acute thyroid eye disease (TED): principles of medical and surgical management. Eye (Lond). 2013 Mar. 27 (3):308-19. [Medline].

 
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Axial MRI taken 3 weeks after the onset of distorted vision in the right eye; visual acuity is reduced to counting fingers at 1 ft. Evidence of optic nerve compression is not seen; disease in the sphenoid sinus is reported.
MRI of same patient as in the image above taken 4 months later. Patient responded well to IV Solu-Medrol, but symptoms returned when steroids were reduced. Large mass compressing the right optic nerve is seen. Biopsy revealed lymphoma.
A 72-year-old man with a moderate decrease in vision in the left eye (20/20 right, 20/25 left). Fundus examination revealed a normal right optic nerve.
Same patient as in image above of a 72-year-old man with a moderate decrease in vision in the left eye (20/20 right, 20/25 left). Fundus examination revealed an atrophic left optic nerve.
Neuroimaging study (MRI of brain and orbits) revealed an extensive meningioma involving the left orbital apex (arrow).
 
 
 
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