Case 3

A 28-year-old with eye pain

Q1

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What additional history do you want to obtain?

Q2

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What physical examinations would you like to perform?

Q3

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What is your leading diagnosis?

Q4

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What is the most likely diagnostic modality?

Q5

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What is your treatment plan for this patient?

Summary

Optic neuritis is an important cause of acute visual loss. It can be associated with multiple sclerosis, and is the presenting symptom in 20% of MS patients. It is most common in women aged 20-40 yo, and follows the geographical distribution of MS (more common in temperate climates compared to tropical), more common in Caucasians. It is caused by acute demyelination of the optic nerve which leads to axon loss. Histologic features are typical of MS plaques including perivascular cuffing, myelin breakdown, and nerve sheath edema. These changes are thought to be T-cell mediated vs. a yet unknown target. B-cell activation vs. myelin basic protection has also been noted.

Clinically, the presentation is usually monocular (90%), and vision loss occurs over hrs to days, peaks in 1-2 weeks, and usually affects central vision. Eye pain is present in 92% of patients and is worse on eye movement. There should be a RAPD if other eye uninvolved. If there is no RAPD, it is possible that the patient has a nonorganic cause of visual loss. Other features include a loss of color vision out of proportion to visual acuity loss, papillitis in 1/3 of patients, (which means that 2/3 of patients present with normal appearing optic nerve), and photopsias (flashes of light with eye movement) in 30% of patients.