Neuro-opth

Question 1

What is the commenst cause of optic neuritis and it’s incidence

Answer 1

Demyelination

• Incidence: 1-3/100,000.
• Occuritns in 70% of people with MS and is the presenting feature in 20%

Question 2

What are the clinical features of typical optic neuritis

Answer 2

• Usually female aged 20-50.
• Pain on eye movement
• Rapid loss in VA over hours to days with deprecated contrast sensitivity/colour vision and or field loss.
• RAPD

Question 3

How to treat typical optic neuritis

Answer 3

• Rule out atypical features/red flags
• Review within 2 weeks to ensure improving
• Then refer on to neuro-opth for further investigation. If not improving then <24hr referral to neuro-opth +/e bloods +/e MRI head/orbit =
• > 90% achieve 6/9 vision although abnormalities of colour/contrast may persist

Question 4

What are atypical features to look that may change management?

Answer 4

• Va <6/60 (CF or less)
• Age >45 or <15
• No pain or intense pain/headache
• Pain or vision loss progressing over two weeks
• Bilateral
• Autoimmune disease/immunosuppression or other neurological symptoms/infections

Signs
- Pale disc in context of no previous MS/demyelination
- Marked papillitis with exudates

Question 5

How to treat atypical optic neuritis

Answer 5

Discuss with neuro-opth/senior:

• Neuro-Opthal bloods: FBC, CRP, ESR, U+E, LFT, ACe, ANA , Syphilis serology, CXR
• MRI brain/orbit:
• Neuro-opth referral within 24 hours

Question 6

What are some main concerns/cause of atypical optic neuritis:

Answer 6

• Compressive: (TEDs or cancer
• inflammation (sarcoma/SLE etc)
• infective (TB/syphilis/Lyme etc)

Question 7

When may you consider giving steroid treatment for suspected typical acute optic neuritis?

Answer 7

If only eye patient and vision worse than 6/12 and following risk and benefits discussion.

Dose:
IVMP 1g daily for 3 days
Then 1mg/kg oral prep for 11 days, then tapered over 3 days

Question 8

If patient is on steroids, what three things do you need to check at every visit?

Answer 8

• IOP
• BP
• BM

Question 9

If a patient has headache, what examination should you do? How can you be sure the headache is not ophthalmic cause?

Answer 9

• Need a full history
• Need a fully examination - including colour vision, visual fields, cranial nerves, proptosis assessment
• If suspicious, may still need formal visual fields