1. Neurologic causes for visual loss in the young adult
Raja Sawaya MD, Nabil El Ayoubi MD, Rola N Hamam MD American University Medical Center, Beirut, Lebanon.
Autoimmune / Inflammatory
Compressive / Malignancy
Ophthalmologic / Cryptogenic
Optic neuritis, MS and NMO present with acute loss of vision in one or both eyes. MS is usually diagnosed by abnormal MRI of the brain and oligoclonal bands in the CSF. Extensive myelitis favors the diagnosis of NMO. Treatment is by steroids and immuno-
suppressive therapy.
Optic nerve sheath meningiomas optic nerve gliomas and internal carotid aneurysms can present with progressive visual loss. Diagnosis is by CT or MRI. Tumors calcify or enhance. Treatment is surgical in case of progressive visual loss. No role for steroids.
Parasitic infection , retinal detachment; papillitis caused by CMV, EBV, cat-scratch disease; Leiber’s optic neuropathy, Rosai Dorfmann histiocytosis, vitamin deficiency, and drug side effect are other causes of visual loss in the young. Still there are cryptogenic causes that respond partially to IVIG.
Infectious / Infiltrative
Ischemic / Vascular
Conclusion
Optic nerve lesions can be secondary to infiltrative disease such as sarcoidosis or infections such as tuberculosis, syphilis or toxocaraiasis. This may present with severe visual loss. Treatment is by prolonged steroid therapy or appropriate antibiotics and recovery is usually partial.
Ischemia of the optic nerve as in AION, of retinal artery occlusion present with acute and severe visual loss. Optic nerve head swelling and altitudinal visual field defects may be classic. The mainstay of treatment is antiplatelets and control of hypertension.
Visual loss in the young adult is not a rare disorder and is a neurologic emergency. Neurologic etiologies for visual loss in the young are considered after ophthalmologic causes have been ruled out. Patients should undergo a full neurologic examination, laboratory, radiographic and evoked potential studies. Treatment is primarily directed to the diagnosed etiology, but saving vision should be the first aim of therapy and immediate treatment with high dose pulse steroids should be initiated even prior to a definite diagnosis, after ruling out infectious causes.

2. Sarcoidosis infiltrating ONH, both eyes
Bilateral ONH swelling and leakage.. Active papillitis

3. Ischemic / Vascular
Anterior ischemic optic neuropathy: I will send you photo of ONH and VF with altitudinal defect
Retinal atery and vein occlusions affect the retina and the not the ON : with findings affecting the retina and not the nerve acutely