Chapter 12. Neuro-ophthalmology
A 32-year-old white woman presents with a 1-day history of progressive monocular vision loss, concomitant with left ocular pain that is exacerbated by eye movements. She was also seeing “flashes of light” and “sparkles” through the affected eye.
Physical examination reveals a visual acuity of 20/20 on the right and 63/100 on the left. There is mild afferent pupillary defect as well as red desaturation on the left.
Which of the following fundoscopy findings is most predictive for later development of multiple sclerosis in this patient?
(B) Mild optic disk edema
(C) Severe optic disk edema
(A) The risk of developing multiple sclerosis (MS) in a patient with optic neuritis (ON) increases with the presence of retrobulbar neuritis.
ON is an inflammatory condition of the optic nerve that most commonly affects white women, with a mean age of onset of 32 years. In a number of patients, ON is the debuting symptom of MS.
ON typically presents with subacute monocular vision loss, which varies in severity from diminished visual acuity to anopsia. Commonly described concomitants include ocular pain exacerbated by eye movement, dyschromatopsia with red color desaturation, afferent pupillary defect, and photopsia. Symptoms that are atypical for ON include bilateral vision loss, onset at age >45, and absence of ocular pain.
Severe optic disk edema, vitreous cells, or retinal hemorrhage are uncommon findings in patients with optic neuritis, and alternative diagnoses should be considered. The most common fundoscopy finding expected would be mild optic disk edema. Notably, the risk of developing MS in patients with retrobulbar neuritis is 31%, versus 14% in patients with anterior neuritis. (Costello, 816–837; Ropper, 238–239)
Costello F. Inflammatory optic neuropathies. Continuum (Minneap Minn). 2014;20(4 Neuro-ophthalmology):816–837.
Ropper A, Samuels M. Adams and Victor Principles of Neurology. 9th ed. New York, NY: McGraw-Hill Professional; 2011.
A 41-year-old woman with a known diagnosis of Hashimoto thyroiditis, controlled on levothyroxine, presents with a 2-day history of subacute bilateral vision loss concomitant with paraparesis and bladder dysfunction. She also complains of concomitant numbness over the lower extremities.
Physical exam reveals bilateral diminished visual acuity of 63/100 on the right and 20/100 on the left. Sensory examination reveals a T-12 sensory level and lower extremity weakness of 3/5 bilaterally.
Which of the following magnetic resonance imagine (MRI) findings would be most compatible with the patient's presentation?