Recently I had a follow-up visit with a 19-year-old male who had just seen an Ophthalmologist for his annual exam.

 

He had been having pain when moving his eyes from side-to-side. After a thorough eye exam he was told it was probably related to sinus or allergy issues and should take Claritin regularly. Then he should see his regular doctor for a follow-up visit.

 

Four days later he felt that things were much better. His blood pressure was normal and his vision was 20/20 in both eyes.

 

There was minimal pain on moving his eyes. He did have some tenderness in the sinus areas of the forehead and cheekbone. But the nasal exam was not all that impressive for significant sinus disease. A thorough neurological exam was also completely normal.
 

While he felt 80-90% better than when he had seen the eye doctor, he did have some sinus issues.

He was told to take Claritin-D which adds a decongestant. Still unsettled by his complaint I told mom to call with an update in two days and if ANYTHING changed he needed to go back to the eye doctor. He did get better and mom forgot to call with an update.
 

However the following week he had gradual decrease of vision of one eye. He didn’t think much of it initially but it progressively got worse. Mom called the eye doctor who saw him immediately and diagnosed him with Optic Neuritis (ON).

 

Optic Neuritis is a condition that occurs when there is swelling, inflammation or irritation of the optic nerve which connects the eye to the brain and allows us to see. The exact cause of ON is uncertain, but it has been associated with a number of viral illnesses such as the flu, measles, mumps, Lyme disease, and cat scratch fever. ON is also associated with Multiple Sclerosis (MS) and may be the initial symptom of this disease. Fifty percent of patients with MS will develop ON.

 

It is felt that ON is a demyelinating disease of the optic nerve.

 

The myelin sheath coats the optic nerve which allows for a speedy transmission of information from the eye to the brain. ON is the result of an auto-immune process whereby the body’s defense system attacks the myelin sheath covering the nerve. ON can occur at any age but is most common in females between the age of 20 and 40. It is more common in Caucasians and Asians than in African-Americans.
 

The symptoms of ON include gradual loss of vision over a few days usually in one eye. But it may be in both eyes 10% of the time.

 

Also there may be blurry vision, loss of part of the field of vision, decrease in color vision, eye pain particularly with movement of the eye and flashing or flickering lights in 30% of cases. If one suspects ON it is important to see an Ophthalmologist as soon as possible. Typically the diagnosis can be made with a thorough eye exam. This includes checking the visual acuity, doing a fundoscopic exam in order to look at the back of the eye and examining the optic nerve for swelling. They will check the peripheral vision and check the pupillary response to light which is often impaired by ON. Most likely an MRI scan of the orbits and brain with a special contrast (galadium) will be ordered. This will not only confirm the demyelinization of the optic nerve, but also look for evidence of MS.

 

While 80% of cases of ON will resolve over 4-12 weeks steroids can dramatically speed up the restoration of vision.

 

Usually this will require an initial phase of IV steroids followed by a tapering oral course. If the ON is associated with MS the response to steroids may not be dramatic. Regardless, a patient with ON must be followed very closely by an Ophthalmologist.

 

My patient was seen right away by the eye doctor who made the diagnosis in the office. His vision improved dramatically after a few days of steroids and we are awaiting approval for the MRI.