Approach to Diagnosis and Management of Optic Neuropathy

1. A D E W I J A Y A , M D – A P R I L 2 0 2 3
Approach to
Diagnosis and Management of
Optic Neuropathy

2. Introduction
 Visual loss is a frequently encountered symptom in
neurologic practice
 It may occur in the background of established
metabolic disorders like diabetes mellitus or appear
as a primary symptom of neurological dysfunction
 Clinical triad: Vision loss, color desaturation,
positive RAPD
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

3. Classification of optic neuropathies
 Optic neuritis (OPN)
 Ischaemic optic neuropathy
 Toxic and nutritional optic neuropathy
 Systemic inflammatory disorders
 Connective tissue disorders and systemic vasculitis
 Inherited optic neuropathies
 Other
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

4. Optic Neuropathies (OPN)
 Isolated OPN
 OPN associated with multiple sclrerosis
 OPN associated with neuromyelitis optica and
spectrum disorders
 Chronic relapsing idiopathic optic neuritis (CRION)
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

5. Ischaemic Optic Neuropathy Toxic and Nutritional ON
 Arteritic
 Non-arteritic
 Drugs: ethambutol,
INH, methotrexate,
vincristine, tamoxifen,
isotretionin,
amiodarone
 Methyl alcohol
 Tobacco (smoking)
 B12 deficiency
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

6. Systemic Inflammatory Disorders
 Sarcoidosis
 Bechet’s syndrome
 Inflammatory bowel disease
 Von Koyangi Harada syndrome
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

7. Connective Tissue Disorders
and Systemic Vasculitis
 Systemic lupus erythematosis
 Sjogrens Syndrome
 Mixed connective tissue disease
 Scleroderma
 Rheumatoid arthritis
 Churg Strauss syndrome
 Wegners granulomatosis
 Granulomatous angiitis
 Poliarteritis nodosa
 Giant cell arteritis
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

8. Inherited Optic Neuropaties
Primary hereditary optic neuropathies
• Leber’s hereditary optic neuropathy
• Autosomal dominant and recessive optic atrophy
Optic neuropathy as a feature of degenerative brain
disease
• Hereditary ataxia (spinocerebellar ataxia, Friedreich’s ataxia)
• Hereditary polineuropathy (Charcot Mariet Tooth disease)
• Hereditary spastic paraplegia
• Storage disorders (lipid storage disorder)
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

9. Other
 Compressive
 Paraneoplastic
 Post radiation
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

10. Clinical Evaluation
Tempo
Acute
Ischaemic
Optic
Neuropathy
Sudden and
painless
Subacute or
Chronic
Compressive
optic nerve
pathology
Insidious and
progressive
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

11. Clinical Evaluation
Age at onset
Elderly with
concomitant history of
weight loss, myalgia, and
fatigue accompanied by
temporal pain
Arteritic form of
ischemic optic
neuropathy due to
temporal arteritis
Young onset, acute
unilateral painful visual
loss particularly in young
women
optic neuritis (OPN)
associated with MS
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

12. Clinical Evaluation
Visual loss
pattern
Central
OPN
compressive
Field defect ischaemic
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

13. Clinical Evaluation
 Ocular pain: retrobulbar neuritis
 Concomitant illness: Coexisting hypertension,
diabetes, and hyperlipidemia favor a diagnosis of
non-arteritic ischemic optic neuropathy
 Drug-induced optic neuropathy may be seen
particularly with Ethambutol, Amiodarone, and anti-
cancer drugs
 Family history: hereditary optic neuropathy
Lepore FE. The origin of pain in optic neuritis. Determinants of pain in 101 eyes with optic neuritis. Arch Neurol 1991;48:748-9.
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

14. Optic Neuritis Investigations and Treatment
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

15. Investigations of Optic Neuropathy
Mustafa, S., & Pandit, L. (2014). Approach to diagnosis and management of optic neuropathy. Neurology India, 62(6), 599.

17. Summary
 Diagnosis is challenging, various etiology
 Clinical triad: visual loss, colour desaturation,
positive RAPD
 Careful clinical investigation needed
 Treatment based on etiology

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