Childhood Optic Neuritis Workup

  • Author: Martha P Schatz, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Dec 5, 2011
 

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 thT1 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 ofT1 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 thT1 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 shT1 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 heT2 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 of Pediatric Ophthalmology & Strabismus (AAPOS), North American Neuro-Ophthalmology Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

John E Carter, MD  Associate Professor, Department of Medicine, Assistant Professor, Department of 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, American Academy of Ophthalmology, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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, and American Ophthalmological Society

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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.

Ralph Garzia, OD  Assistant Dean for Clinical and Academic Programs, Associate Professor, College of Optometry, University of Missouri at St Louis

Ralph Garzia, OD is a member of the following medical societies: American Academy of Optometry and American Optometric Association

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.

References

  1. Langer-Gould A, Zhang JL, Chung J, Yeung Y, Waubant E, Yao J. Incidence of acquired CNS demyelinating syndromes in a multiethnic cohort of children. Neurology. Sep 20 2011;77(12):1143-8. [Medline].

  2. Waldman AT, Stull LB, Galetta SL, Balcer LJ, Liu GT. Pediatric optic neuritis and risk of multiple sclerosis: Meta-analysis of observational studies. J AAPOS. Oct 2011;15(5):441-6. [Medline].

  3. Wilejto M, Shroff M, Buncic JR, et al. The clinical features, MRI findings, and outcome of optic neuritis in children. Neurology. Jul 25 2006;67(2):258-62. [Medline].

  4. Lucchinetti CF, Kiers L, O'Duffy A, et al. Risk factors for developing multiple sclerosis after childhood optic neuritis. Neurology. Nov 1997;49(5):1413-8. [Medline].

  5. Banwell B, Tremlett H. Coming of age: the use of immunomodulatory therapy in children with multiple sclerosis. Neurology. Mar 8 2005;64(5):778-9. [Medline].

  6. Beck RW. Optic neuritis. In: Miller NR, Newman NJ, ed. Walsh and Hoyt's Clinical Neuro-ophthalmology. 5th ed. Baltimore: Lippincott Williams & Wilkins; 1998.

  7. Beck RW, Trobe JD. What we have learned from the Optic Neuritis Treatment Trial. Ophthalmology. Oct 1995;102(10):1504-8. [Medline].

  8. Bonhomme GR, Liu GT, Balcer LJ. Isolated pediatric optic neuritis. Brain MRI abnormalities and risk of multiple sclerosis. Paper presented at: Annual Meeting of the North American Neuro-ophthalmology Society; 2005.

  9. Carroll DM, Franklin RM. Leber's idiopathic stellate retinopathy. Am J Ophthalmol. Jan 1982;93(1):96-101. [Medline].

  10. Dreyer RF, Hopen G, Gass JD, et al. Leber's idiopathic stellate neuroretinitis. Arch Ophthalmol. Aug 1984;102(8):1140-5. [Medline].

  11. Farris BK, Pickard DJ. Bilateral postinfectious optic neuritis and intravenous steroid therapy in children. Ophthalmology. Mar 1990;97(3):339-45. [Medline].

  12. Gass JD. Diseases of the optic nerve that may simulate macular disease. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol. Sep-Oct 1977;83(5):763-70. [Medline].

  13. Hierons R, Lyle TK. Bilateral retrobulbar optic neuritis. Brain. 1959;82:56-67.

  14. Keast-Butler J, Taylor D. Optic neuropathies in children. Trans Ophthalmol Soc U K. Apr 1980;100:111-8. [Medline].

  15. Kennedy C, Carroll FD. Optic neuritis in children. Arch Ophthalmol. 1960;73:747-755.

  16. King MH, Cartwright MJ, Carney MD. Leber's idiopathic stellate neuroretinitis. Ann Ophthalmol. Feb 1991;23(2):58-60. [Medline].

  17. Koraszewska-Matuszewska B, Samochowiec-Donocik E, Rynkiewicz E. [Optic neuritis in children and adolescents]. Klin Oczna. Jun 1995;97(6):207-10. [Medline].

  18. Kriss A, Francis DA, Cuendet F, et al. Recovery after optic neuritis in childhood. J Neurol Neurosurg Psychiatry. Oct 1988;51(10):1253-8. [Medline].

  19. Maitland CG, Miller NR. Neuroretinitis. Arch Ophthalmol. Aug 1984;102(8):1146-50. [Medline].

  20. Meadows SP. Doyne memorial lecture (1969). Retrobulbar and optic neuritis in childhood and adolescence. Trans Ophthalmol Soc U K. 1970;89:603-38. [Medline].

  21. Morales DS, Siatkowski RM, Howard CW, et al. Optic neuritis in children. J Pediatr Ophthalmol Strabismus. Sep-Oct 2000;37(5):254-9. [Medline].

  22. Nakao Y, Omoto T, Shimomura Y. Optic neuritis in children. Folia Ophthalmol Jpn. 1983;34:496-498.

  23. Neetens A, Smets RM. Leber's neurogenic stellate maculopathy. Neuro Ophthalmol. 1987;7:315-328.

  24. Pohl D, Rostasy K, Gartner J, et al. Treatment of early onset multiple sclerosis with subcutaneous interferon beta-1a. Neurology. Mar 8 2005;64(5):888-90. [Medline].

  25. Riikonen R, Donner M, Erkkilä H. Optic neuritis in children and its relationship to multiple sclerosis: a clinical study of 21 children. Dev Med Child Neurol. Jun 1988;30(3):349-59. [Medline].

  26. Rothermel H, Hedges TR 3rd, Steere AC. Optic neuropathy in children with Lyme disease. Pediatrics. Aug 2001;108(2):477-81. [Medline].

  27. Rush JA. Idiopathic optic neuritis of childhood. J Pediatr Ophthalmol Strabismus. May-Jun 1981;18(3):39-41. [Medline].

 
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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 NeuritisPediatric Optic Neuritis
UnilateralBilateral
Retrobulbar optic neuritisPapillitis
Commonly associated with pain on eye movementsCommonly associated with headache
Most often idiopathicMost often postinfectious or postimmunization
High probability of recurrent inflammatory demyelinating events in the CNS and a diagnosis of MSLow probability of recurrent demyelinating events and a diagnosis of MS
Table 2. Equivalent Doses of Commonly Used Corticosteroid Medications
Corticosteroid DrugApproximate Equivalent Dose
Prednisone5 mg
Prednisolone5 mg
Methylprednisolone4 mg
Dexamethasone0.75 mg
Table 3. Life-Table Analysis of the Risk for Development of MS in Children With an Isolated Attack of Optic Neuritis[4]
AgeRisk for Development of MS
10 years13%
20 years19%
30 years22%
40 years26%
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