Optic neuritis

Last reviewed: March 2019

Last updated: March 2018

Summary

May involve the retrobulbar (retrobulbar neuritis) or the intrabulbar (papillitis) portion of the optic nerve, or both.

Idiopathic ON, the most common form of ON, is an inflammatory optic neuropathy in the absence of evidence of a systemic inflammatory disease.

May occur in isolation or be a manifestation, often the first, of multiple sclerosis (MS).

Investigations including MRI of the brain can help predict the risk of conversion to MS and can dictate early intervention with disease-modifying treatments (interferon-beta, glatiramer acetate) that reduces the risk of conversion to MS.

Acute treatment for idiopathic ON includes intravenous corticosteroid treatment followed by oral prednisone or observation alone.

Oral prednisone alone should not be used in the treatment of idiopathic acute ON.

Definition

Optic neuritis (ON) represents inflammation of the optic nerve. By far the most common form is idiopathic ON, which is a primary demyelinating disease occurring in isolation or as part of multiple sclerosis (MS). [1] [2] When in isolation, primary demyelinating ON is considered a forme fruste of MS. ON manifests as the subacute or acute onset of pain in the eye and pain with eye movements and loss of vision, typically with central or centrocecal scotoma that usually reaches a nadir at approximately 1 to 2 weeks. ON recovers over several months, with ultimate visual acuity that is possibly reduced but seldom severely so.

History and exam

Key diagnostic factors

periorbital/retro-ocular pain
loss of visual acuity with scotoma
color desaturation/loss of color vision
relative afferent papillary defect (RAPD)

Full details

Other diagnostic factors

optic disk swelling
neurologic abnormalities of multiple sclerosis
Uhthoff phenomenon
phosphenes
Pulfrich phenomenon
perivenous sheathing

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Risk factors

age 30 to 50 years
female sex
white ethnicity
HLA DR(2)15 genetic mutation
EBV infection later in childhood
childhood in higher latitudes
presence of autoimmune disease
exposure to infectious diseases, such as Lyme disease and syphilis

Full details

Diagnostic investigations

1st investigations to order

MRI of the optic nerves
CBC
ESR
C-reactive protein
venereal disease research laboratory (VDRL)
uric acid
serum ACE
ANA

Full details

Investigations to consider

Lyme titer
B12 and folate
cerebrospinal fluid analysis
neuromyelitis optica (NMO) antibody (aquaporin-4, AQP4 antibody) and anti-myelin oligodendrocyte glycoprotein (MOG) antibody

Full details

Treatment algorithm

ACUTE

acute episode

ONGOING

coexisting inflammatory diseases (e.g., SLE or sarcoidosis)

Contributors

Authors VIEW ALL 

Cris S. Constantinescu, MD, PhD

Chair of Neurology

School of Medical and Surgical Sciences

Division of Stroke Medicine

University of Nottingham

Nottingham

Disclosures

CSC has received research support, support for travel to scientific meetings, or consultancy fees from Biogen, Bayer, Genzyme, Merck, Morphosys, Novartis, Roche, Sanofi-Pasteur, MSD, and Teva. CSC is an author of a number of references cited in this topic.

Thomas M. Bosley, MD

Knights Templar Eye Foundation Professor of Ophthalmology

Wilmer Eye Institute

Johns Hopkins University

Baltimore

Disclosures

TMB declares that he has no competing interests.

Peer reviewers VIEW ALL 

Gus Gazzard, MA, MBBChir, MD, FRCOphth

Consultant Ophthalmic Surgeon

King's College Hospital

Honorary Research Fellow

Institute of Ophthalmology

London

Disclosures

GG declares that he has no competing interests.

John Selhorst, MD

Professor

Department of Neurology and Psychiatry

Saint Louis University

St. Louis

Disclosures

JS declares that he has no competing interests.

Efstratios Mendrinos, MD

Department of Ophthalmology

Geneva University Hospitals

Geneva

Switzerland

Disclosures

EM declares that he has no competing interests.

Jonathan Smith, MD

Specialist Registrar in Ophthalmology

Royal Victoria Infirmary

Newcastle

Disclosures

JS declares that he has no competing interests.

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Optic neuritis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acute episode

coexisting inflammatory diseases (e.g., SLE or sarcoidosis)

Contributors

Authors VIEW ALL 

Cris S. Constantinescu, MD, PhD

Disclosures

Thomas M. Bosley, MD

Disclosures

Peer reviewers VIEW ALL 

Gus Gazzard, MA, MBBChir, MD, FRCOphth

Disclosures

John Selhorst, MD

Disclosures

Efstratios Mendrinos, MD

Disclosures

Jonathan Smith, MD

Disclosures

Differentials

Guidelines

Patient leaflets

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