eMedicine Specialties > Ophthalmology > Optic Nerve

Optic Neuritis, Adult: Differential Diagnoses & Workup

Author: Erhan Ergene, MD, Clinical Assistant Professor, Department of Neurology, University of Illinois College of Medicine at Peoria; Medical Director, Comprehensive Epilepsy Program and Clinical Neurophysiology, Illinois Neurological Institute at OSF Saint Francis Medical Center
Coauthor(s): Nancy A Machens, APN, CNP, Professor of Nursing, Bradley University; Advanced Practice Nurse, Nurse Practitioner, Department of Neurology, Illinois Neurological Institute at OSF Saint Francis Medical Center
Contributor Information and Disclosures

Updated: Jul 30, 2009

Differential Diagnoses

Branch Retinal Artery Occlusion
Optic Neuropathy, Anterior Ischemic
Central Retinal Artery Occlusion
Optic Neuropathy, Compressive
Glaucoma, Angle Closure, Acute
Sarcoidosis
Herpes Simplex
Sudden Visual Loss
Meningioma, Optic Nerve Sheath
Thyroid Ophthalmopathy
Ocular Manifestations of Syphilis
Toxic/Nutritional Optic Neuropathy

Other Problems to Be Considered

Neuromyelitis optica
Hereditary optic neuropathies
Nutritional optic neuropathies
Wegener granulomatosis
Necrotizing herpetic retinopathy in persons who are immunocompromised

Workup

Laboratory Studies

  • Blood tests, such as erythrocyte sedimentation rate, thyroid function tests, antinuclear antibodies, angiotensin-converting enzyme, rapid plasma reagin, and mitochondrial DNA mutation studies can be considered to exclude causes of optic neuropathy other than demyelinating optic neuritis (ON). However, in a typical case of ON without any clinical signs and symptoms of a systemic disease, the yield from these tests is extremely low.
  • CSF analysis often is noncontributory to diagnosis. However, the presence of myelin basic protein, oligoclonal bands, and elevated IgG index and synthesis rate in the CSF supports the diagnosis of MS, and, even in the absence of other signs of MS during the initial presentation, patients with positive findings of demyelination in the CSF are more likely to develop MS in the long term.25
  • Neuromyelitis optica-IgG is a specific autoantibody marker for neuromyelitis optica, which is a severe form of a demyelinating disease, likely distinct from MS, that affects the optic nerves and the spinal cord, causing recurrent attacks of blindness and paralysis.26,27

Imaging Studies

  • Magnetic resonance imaging (MRI) is a highly sensitive and specific tool in assessing inflammatory changes in the optic nerves (see Media file 1) and helps to rule out structural lesions. In addition, MRI may have a value in predicting future development of MS in patients presenting with first time acute ON.28,29,30,31,32,33,34 MRI performed at the initial presentation reveals that 10-20% of these patients may have clinically silent demyelinative lesions elsewhere in the brain. MRI at 3.0 T is more sensitive to hyperintense lesions than MRI at 1.5 T.35 These patients are more likely to develop definite MS in the long term than patients with isolated ON. The Optic Neuritis Treatment Trial (ONTT) reported the 10-year risk of MS to be 56% with at least one MR T2 lesion.16
  • Utilization of fat saturation techniques helps to visualize gadolinium enhancement of the optic nerve and is the best imaging technique to visualize inflammation of the optic nerve.
  • In addition to the MRI of the optic nerves and brain/brainstem, an MRI of the spinal cord is indicated in patients with suspected neuromyelitis optica (NMO). An MRI of the spinal cord characteristically shows cord swelling, signal changes, and enhancement extending over several levels consistent with longitudinally extensive myelitis.36

A case of acute optic neuritis. A. 1.5 Tesla, con...

A case of acute optic neuritis. A. 1.5 Tesla, contrast-enhanced spin echo T1-weighted, fat-suppressed coronal MRI through the orbits shows enlargement and contrast enhancement of the left optic nerve in the retrobulbar portion (arrow). B. Coronal spin echo T1-weighted, fat-suppressed MRI of the same patient shows enlargement and contrast enhancement of the nerve in a parasagittal oblique section (arrow).

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A case of acute optic neuritis. A. 1.5 Tesla, con...

A case of acute optic neuritis. A. 1.5 Tesla, contrast-enhanced spin echo T1-weighted, fat-suppressed coronal MRI through the orbits shows enlargement and contrast enhancement of the left optic nerve in the retrobulbar portion (arrow). B. Coronal spin echo T1-weighted, fat-suppressed MRI of the same patient shows enlargement and contrast enhancement of the nerve in a parasagittal oblique section (arrow).

Other Tests

  • Visually-evoked potentials (VEPs) are an important means of evaluating patients with suspected ON and may be abnormal, even when MRI of the optic nerve is normal.
    • VEP often shows a loss of P100 response in the acute phase. P100 recovers with time, but it usually shows a markedly prolonged latency that persists indefinitely even after clinical recovery.
    • VEP may be abnormal in patients without a past history of ON, thereby providing evidence of subclinical involvement of the optic nerve. For this reason, VEP often is performed in patients with a suspected diagnosis of MS.

More on Optic Neuritis, Adult

Overview: Optic Neuritis, Adult
Differential Diagnoses & Workup: Optic Neuritis, Adult
Treatment & Medication: Optic Neuritis, Adult
Follow-up: Optic Neuritis, Adult
Multimedia: Optic Neuritis, Adult
References
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References

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Further Reading

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Keywords

adult optic neuritis, ON, optic nerve, multiple sclerosis, MS, neuromyelitis optica, NMO

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Contributor Information and Disclosures

Author

Erhan Ergene, MD, Clinical Assistant Professor, Department of Neurology, University of Illinois College of Medicine at Peoria; Medical Director, Comprehensive Epilepsy Program and Clinical Neurophysiology, Illinois Neurological Institute at OSF Saint Francis Medical Center
Erhan Ergene, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Nancy A Machens, APN, CNP, Professor of Nursing, Bradley University; Advanced Practice Nurse, Nurse Practitioner, Department of Neurology, Illinois Neurological Institute at OSF Saint Francis Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American College of Physician Executives, American Society of Contemporary Ophthalmology, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada
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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