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Childhood Optic Neuritis Workup

  • Author: Martha P Schatz, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Nov 30, 2015
 

Laboratory Studies

Lumbar puncture with measurement of opening pressure excludes papilledema secondary to intracranial hypertension.

Cerebrospinal fluid (CSF) studies may indicate the presence of a simultaneous meningitis or encephalitis, but a mild lymphocytic pleocytosis may be present with optic neuritis.

NMO (neuromyelitis optica) antibody in serum helps establish a diagnosis of neuromyelitis optica.

Systemic lab studies can be performed directed by features in the history and physical examination consistent with other non–immune-mediated causes of optic neuritis.

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Imaging Studies

An MRI of the brain and orbits with contrast should be performed.

Enhancement of the optic nerve in the orbit or the intracranial segment of the optic nerve or of the chiasm is helpful in confirming the diagnosis. Some enlargement of the optic nerve is present in optic neuritis, and a diagnosis of optic nerve glioma should not be made unless the clinical course dictates reconsideration of the diagnosis of optic neuritis.

An MRI should exclude extrinsic compressive lesions.

Meningeal enhancement suggests some form of infectious or noninfectious meningitis and may merit additional workup and different therapy.

Changes in the CNS white matter may confirm other neurologic involvement found on physical examination, may affect the prognosis of MS in the future, or may indicate the presence of acute disseminated encephalomyelitis. One third of children with optic neuritis will have asymptomatic white matter lesions of the brain as compared to one half of adults with optic neuritis.

The images below depict characteristics relevant to a diagnosis of optic neuritis.

T1 contrast enhanced axial section of an MRI of th T1 contrast enhanced axial section of an MRI of the orbital optic nerve of a child with optic neuritis on the left side. The arrows point to the left optic nerve that enhances along its entire orbital course.
T1 contrast enhanced coronal section of the MRI of T1 contrast enhanced coronal section of the MRI of the orbital optic nerve. The arrow points to the enhancing left optic nerve.
T1 contrast enhanced axial section of an MRI of th T1 contrast enhanced axial section of an MRI of the intracranial optic nerves. Enhancement of both optic nerves is seen. The arrow indicates the left optic nerve.
T1 contrast enhanced coronal section of the MRI sh T1 contrast enhanced coronal section of the MRI showing the optic nerves that both enhance. The arrow points to the left optic nerve.
T2 axial section of an MRI through the cerebral he T2 axial section of an MRI through the cerebral hemisphere of a boy with bilateral optic neuritis. Note high-signal abnormalities in the cerebral white matter that are most prominent in the posterior hemispheres. This is suspicious for mild acute disseminated leukoencephalitis.

To either diagnose or exclude neuromyelitis optica (Devic disease), an MRI of the spinal cord with contrast is necessary if symptoms and signs consistent with a spinal cord process are present.

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Contributor Information and Disclosures
Author

Martha P Schatz, MD Chief, Pediatric Ophthalmology Service, Clinical Professor of Ophthalmology, University of Texas Health Science Center at San Antonio

Martha P Schatz, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, North American Neuro-Ophthalmology Society, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

Gerhard W Cibis, MD Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas School of Medicine

Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Ophthalmological Society

Disclosure: Nothing to disclose.

John E Carter, MD Professor, Departments of Neurology and Ophthalmology, University of Texas Health Science Center at San Antonio

John E Carter, MD is a member of the following medical societies: American Academy of Neurology, North American Neuro-Ophthalmology 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.

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Optic disc swelling in the right eye and left eye in a child with bilateral optic neuritis.
Neuroretinitis in the right eye of an adolescent with cat scratch disease. The optic nerve is swollen, and a deposition of yellowish exudate in the nerve fiber layer of the macula produces a macular star.
T1 contrast enhanced axial section of an MRI of the orbital optic nerve of a child with optic neuritis on the left side. The arrows point to the left optic nerve that enhances along its entire orbital course.
T1 contrast enhanced coronal section of the MRI of the orbital optic nerve. The arrow points to the enhancing left optic nerve.
T1 contrast enhanced axial section of an MRI of the intracranial optic nerves. Enhancement of both optic nerves is seen. The arrow indicates the left optic nerve.
T1 contrast enhanced coronal section of the MRI showing the optic nerves that both enhance. The arrow points to the left optic nerve.
T2 axial section of an MRI through the cerebral hemisphere of a boy with bilateral optic neuritis. Note high-signal abnormalities in the cerebral white matter that are most prominent in the posterior hemispheres. This is suspicious for mild acute disseminated leukoencephalitis.
T2 axial sections of MRI of a man with optic neuritis showing scattered white matter lesions. The arrows point to 2 examples of the numerous lesions.
Table 1. Comparison of Features of Optic Neuritis in Adults and Children
Adult Optic Neuritis Pediatric Optic Neuritis
Unilateral Bilateral
Retrobulbar optic neuritis Papillitis
Commonly associated with pain on eye movements Commonly associated with headache
Most often idiopathic Most often postinfectious or postimmunization
High probability of recurrent inflammatory demyelinating events in the CNS and a diagnosis of MS Low probability of recurrent demyelinating events and a diagnosis of MS
Table 2. Equivalent Doses of Commonly Used Corticosteroid Medications
Corticosteroid Drug Approximate Equivalent Dose
Prednisone 5 mg
Prednisolone 5 mg
Methylprednisolone 4 mg
Dexamethasone 0.75 mg
Table 3. Life-Table Analysis of the Risk for Development of MS in Children With an Isolated Attack of Optic Neuritis [7]
Age Risk for Development of MS
10 years 13%
20 years 19%
30 years 22%
40 years 26%
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