1. EBM Case discussion 報告者： Intern 100.12.09

2. General datas 26-year old male BW 75kg

3. Chief Complaint Acute onset eye pain(ou) for several days

4. Present Illness This 26-year-old man who had history of GI bleeding at childhood due to ingest detergent reagent. This time he suffered from acute onset eye pain(ou) for several days. Symptoms including blurred vision(od) and eye pain on eye movement for 3 days were noted. For help he went to OPD on 2011/12/12.

5. Present Illness Exam on OPD PT OD:15.0mmHg OS:14.7mmHg VA OD:cf30cm OS:0.2 EOM: OD, gaze to left, decreased fd: disc np color test 0/13 Rx: refer to ER for OPTICAL CT, R/O ORBITAL MYOSITIS(od)

6. Course and treatment 2011/12/12 2011/12/15 At OPD S: feel brighter in right eye today, feel less pain when eyemovement in right eye O: VA OD:0.5 OS:0.2 PT OD:11mmHg OS:10mmHg EOM: normal F'd: macula:np disc:pinkish C/D od pinkish, mild disc swelling at upper and lower part os pinkish, clear disc Color test od 7/13 RAPD (relative afferent pupillary defect): OD positive A:Review CT: significant enlargement of retrobulbar optic nerve (OD) OPTICAL CT Tx : Prednisolone 5mg/tab 4pc tid Chloramphenicol 0.25 oph soln 5ml/bot qid

7. Course and treatment 2011/12/22 O: VA OD:1.0 OS:0.9-2 PT OD:14mmHg OS:14mmHg Pupil: L/R +/+, isocoric RAPD(-)(od) Lens: od NS(-),CO(-), PSC(-) os NS(-),CO(-), PSC(-) F'd: macula:np Color test od 13/13 os 13/13 A: RETROBULBAR NEURITIS (ACUTE) P: tx: tapper Prednisolone 5mg/tab 3pc tid

8. Course and treatment 2011/12/22 O: PT OD:16.7mmHg OS:17mmHg VA OD:0.9-2 OS:0.8 F'd: macula:np disc:pinkish C/D od pinkish, disc swelling at upper and lower part Color test od 13/13 os 13/13 A: RETROBULBAR NEURITIS (ACUTE) P: tx: tapper Prednisolone 5mg/tab 1pc tid

9. Discussion

11. Optic neuritis an inflammatory, demyelinating condition that causes acute, usually monocular, visual loss. typically affects young adults. Women are affected more often than men(with mean age of 32) Highly associated with multiple sclerosis (MS) – presenting feature of MS in 15 to 20 percent of patients and occurs in 50 percent at some time during the course of their illness

12. Symptoms acute unilateral vision loss (90%) – Bilateral optic neuritis is more common in children younger than 12 to 15 years old and also in Asian and black South African patients Vision loss typically develops over a period of hours to days, peaking within one to two weeks – scotoma (45%) and blur (40%). Eye pain occurred in 92 percent of patients in the ONTT and often worsened with eye movement

13. Signs Rapid afferent pupillary defect decreased visual acuity – ranged from 20/25 to 20/190 (median visual acuity 20/60) Dyschromatopsia is common, particularly red – Loss of color of vision out of proportion to the loss of visual acuity is specific to optic nerve pathology. – Abnormal color vision by Ishihara plates was found. Various visual field defect patterns can be seen (diffuse, altitudinal, quadrantanopic, centrocecal, hemianopic…)

14. Funduscopic examination Papillitis with hyperemia and swelling of the disk, blurring of disk margins, and distended veins is seen in one-third of patients with optic neuritis Two-thirds of these patients have retrobulbar neuritis with a normal funduscopic examination

15. Magnetic resonance imaging MRI of the brain and orbits with gadolinium contrast provides confirmation of the diagnosis of acute demyelinating optic neuritis (95%)and important prognostic information regarding the risk of developing MS.

16. PROGNOSIS-1 visual recovery – Without treatment, vision begins to improve after a few weeks – 90 percent have 20/40 or better vision at one year recurrence of optic neuritis – 35 percent recurrence of optic neuritis at 10 years: 14 percent in the original eye, 12 percent in the other eye, and 9 percent in both eyes risk of multiple sclerosis (MS) – five-year incidence of clinically definite MS was 30 percent following a first episode of idiopathic demyelinating optic neuritis, 40 percent at 12 years and 50 percent at 15 years

17. PROGNOSIS-2 risk of multiple sclerosis (MS) Age – Risk of MS is lower if the initial attack of optic neuritis occurs in childhood – Among adults, patients who present with optic neuritis at an older age (greater than 35 to 40 years) may be somewhat less likely to develop MS Gender MRI abnormalities – In the ONTT, the risk of MS after 15 years was 72 percent among those with one or more lesions on MRI versus 25 percent among those with no lesions – The risk did not significantly differ between those with single versus multiple lesions. Recurrent episode of optic neuritis

18. Treatment Corticosteroids Alternative treatments used for acute neuroimmunologic disease include intravenous immunoglobulin (IVIG) and plasma exchange. Other immune modulator – Interferon beta-1a – Glatiramer acetate

19. Treatment-2 Optic Neuritis Treatment Trial (ONTT) shows... Treatment with high-dose, intravenous corticosteroids followed by oral corticosteroids accelerated visual recovery but provided no long-term benefit to vision. Treatment with standard-dose oral prednisone alone did not improve the visual outcome and was associated with an increased rate of new attacks of optic neuritis. Treatment with the intravenous followed by oral corticosteroid regimen provided a short-term reduction in the rate of development of multiple sclerosis, particularly in patients with brain MRI changes consistent with demyelination. However, by 3 years of follow up, this treatment effect had subsided.

20. Other things ONTT tells us.. Visual recovery begins rapidly (within 2 weeks) in most optic neuritis patients without any treatment, and then improvement continues for up to 1 year. Although most patients recover to 20/20 or near 20/20 acuity, many still have symptomatic deficits in vision. The probability of a recurrence of optic neuritis in either eye within 5 years is 28 percent. Visual recovery after a second episode in the same eye is generally very good.

21. Reference UpToDate MD Consult Optic neuritis treatment trial (ONTT)