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Update on Optic Neuritis and the role of OCT In Multiple Sclerosis
- 1. Update on Optic Neuritis and OCT in MS Raed Behbehani , MD FRCSC
- 2. Optic Neuritis • Young, female • Pain ( dull-aching , peri-ocular headache , worse with EOM) • Visual acuity can be normal. • RAPD • Visual field defect • Fundus : 60%-70% Normal (retrobulbar neuritis)
- 3. Atypical optic neuritis “Red Flags” • Age <12 years or >50 years • Severe loss of vision (NLP) , Bilateral onset in an adult, no improvement after 6 weeks , progressive course. • No pain. • Ocular findings : severe disc edema , marked hemorrhages, uveitis, exudate, retinitis, phelbitis • Recurrences within a short interval or during steroid taper. • Pre-existing systemic diagnosis ( Cancer, CT disease, Vasculitis, immunosuppression)
- 4. International Consensus Diagnostic Criteria for Neuromyelitis Optica Spectrum Disorders 2015
- 5. Is it NMO-Optic Neuritis ? • Unilateral ON , but can be bilateral . • Females > Males (9:1) • More rapid and severe vision loss . • Mild disc edema or normal .
- 6. NMO ON • CSF Pleocytosis ( > 50 WBC , PMN) • Oligocloncal bands uncommon .
- 8. Neuro-imaging NMO Khanna et al: J Neuro-Ophthalmol 2012
- 9. Neuro-imaging in NMO Bennett: J Neuro-Ophthalmol 2016; 36: 238-245
- 10. Anti-MOG Optic Neuritis • Anti-AQP4 antibodies 2004 • Anti-MOG (unique subset) • Inflammatory demyelinating disorder (NMOSD-like) and ADEM. • Not found in patients with MS nor AQP4 Ab .
- 11. How do I suspect MOG-optic Neuritis ? • Recurrent (50%-80%) , bilateral (50%) • Severe Disc edema in 86% (unlike typical ON) . • Disc hemorrhages (atypical for ON). • Exquisite sensitivity to steroids (CRION). • Vision loss is more severe at onset but better prognosis for recovery .
- 12. Neuro-imaging in MOG Optic Neuritis Chen et al. AJO 2018
- 13. MOG-IgG-associated ON, encephalitis, and myelitis (MONEM) Dos Passos et al. 2018
- 14. Acute treatment for MOG Optic Neuritis • Overall better prognosis than AQP4 . • Some patients may end with severe loss of vision . • IV steroids • PLEX if not improving or severe loss of vision at onset . • PLEX works better if given early .
- 15. Chronic Treatment for MOG Optic Neuritis
- 16. Pediatric Optic Neuritis • Bilateral with papilitis . • Para-infectious • Risk of MS was 36% at 2 years ( Higher in bilateral optic neuritis ).
- 17. Pediatric Optic Neuritis and Risk of MS Ann Neurology 2015
- 18. Pediatric Optic Neuritis and NMO • AQP4-IgG was associated with early recurrence and visual impairment. Absoud et al. 2015 • Negative AQP4-IgG associated with physical disability . Absoud et al. 2015 • Rituximab is the first choice. (Oliveri et al. 2016 , Chitnis et al. 2016)
- 19. OCT in MS Raed Behbehani , MD FRCSC
- 20. Optical Coherence Tomography • Non-invasive imaging technique routinely used in ophthalmology (glaucoma , retinal diseases) • The retina contains axons and glia but no myelin , thus ideal to monitor neurodegeneration. • Quantitative Measurement of retinal nerve fiber layer (RNFL) , macular thickness (MT), Ganglion cell layer (GCL). • Qualitative assessment (Ultra-high resolution).
- 24. How Can OCT Help in MS? • Diagnose sub-clinical optic neuropathy in MS • Differentiate NMOSD optic neuritis from demyelinating optic neuritis • Predict progression and disability in MS • Assessment of disease activity • Outcome measure for neuro-protection • Correlates with brain atrophy
- 25. Why OCT
- 26. Optic Neuropathy in MS • Post-mortem analysis show that most MS have changes in the optic nerve and RNFL in 94%-99% (Ikuta and Zimmerman, 1976; Toussaint et al., 1983 , Green et al. 2010) • PRNFL thinning of around 20.38 um in MS eyes with history of ON , and 7.08 u in MS eyes without history of ON.
- 27. Should Optic Nerve Lesion Added to Diagnostic Criteria for MS ? Filippi et al. MAGNIMS consensus and Guidelines . Lancet Neurology 2016
- 28. OCT for Diagnosing Optic Neuritis
- 29. OCT in Optic Neuritis
- 30. Inter-Eye OCT difference in Optic Neuritis
- 31. Differentiation of NMOSD from MS • RNFL thickness was significantly worse in NMO than in RRMS (Bichuetti et al, 2013) • RNFL 41 um thickness is 100% specific for NMO . (Bichuetti et al, 2013) • RNFL loss tends to be more diffuse in NMO , while in MS it’s more temporal.
- 32. OCT in NMO JL Benett et al . MSJ 2015
- 33. OCT in MS vs NMO
- 34. OCT Predicts Disability • PRNFL =< or equal to 87 μm (Cirrus) or 88 um (Spectralis) had double the risk of disability worsening at any time after the 1st and up to the 3rd years of follow-up • Risk was increased by nearly four times after the third and up to the 5th year.
- 35. Button et al. Neurology 2017 Outcome Measure For Neuro-protection
- 37. Disease Activity Pisa et al. Neurology 2017 NEDA is associated with a relatively preserved RNFL over 2 years. A greater neuroretinal loss was detected even in patients with clinical evidence of disease activity independently from changes in brain MRI lesions NEDA had RNFL loss of 20.93 mm while patients with active disease had 22.83 mm (t test; p , 0.001).
- 39. Neuroprotection
- 40. RNFL and Brain Atrophy Saidha et al. Ann Neurology 2015 GCIP atrophy correlates well with brain substructure atrophy on MRI . Retrograde trans-synaptic axonal degeneration, and clinically mirrors disability progression.
- 41. Ongoing Trials Using OCT Nolan et al. JNO 2018
- 42. Summary • Typical demyelinating Optic neuritis is a clinical diagnosis . • NMO Optic neuritis should suspected in cases of ON with poor recovery and some neuro-radiologic and OCT findings . • Our understanding of the mechanisms of diseases is evolving thanks to new ultra-high resolution OCT. • The non-invasiveness and the reporducibility of OCT makes it ideal to assess neuroprotective effects of drugs in trials.
Editor's Notes
- You all know the classic presentation of ON . This is the typical profile of an optic neuritis patient..
- These are some of the features that should alert you that you are not dealing with a typical ON.
- You are all familiar with the new revised classification of NMOSD , which has allowed us now to diagnose more cases of NMOSD than before. It’s critical since the treatment is drastically different than MS. So now you can it can be AQP4 positive + core clinical characteristic (of which ON is one) Patients with NMOSD who do not have detectable AQP4-IgG must have a minimum of 2 core clinical presentations, and 1 presentation must be ON, TM, or an area postrema syndrome.
- There are some neuro-radiologic features that can give a clue that this is NMOSD Unilateral or bilateral increased T2 signal or T1 gadolinium enhancement within optic nerve or optic chiasm; relatively long lesions (e.g., those extending more than half the distance from orbit to chiasm) and those involving the posterior aspects of the optic nerves or the chiasm are associated with NMO You know you don’t need an MRI to to diagnose optic neuritis as the diagnosis can be made clinically nor orbital MRI is needed for typical demyelinating ON but MRI orbit is useful to distinguisg which type of ON we are dealing with.
- In fact some have reported that posterior optic nerve and chaismal involvement occurred ONLY in NMO . Posterior optic nerve involvement in the NMO group, with chiasmatic enhancement exclusively seen in NMO-related ON (3 patients, P = 0.0179). Chiasmal enhancement/enlargement and bilateral enhancement of the optic nerves was exclusively present in the NMO group. Other differential dagnoses based on this neurorad picture : Sarcoid , TB , Infiltrative disorders (IgG4)
- Sparing of the cortex . LETM > 3 segments
- On MRI : the longitudinally extensive lesions seen and the ”perineuritis” is fairly specific sign of MOG ON. (50%)
- MOG can present like NMOSD . This case fullfuils the criteria of NMOSD (bilateral ON followed by LETM) but is AQP4 negative but MOG is positive . Therefore , in patients with LETM and AQP4 AB negative , always test for MOG . ’H-sign” : on axial images of SC . Signal abnormality is restricted to gey matter .
- Because of the high rate of recurrence and the possibility of deficit (visual loss ). IV steroids 5 days but generally taper slowly (6-12 weeks) to prevent recurrence . Generally speaking , severe single attack or recurrent 2-3 attacks warrant immunosppressive treatment . Rituximab is effective in MOG but not as effective as in AQP4 Ab pos NMOSD. There is some encodotal evidence that showed IVIG monthly may be more effective in reducing relapses than immunosuppressive therapy . Persistent MOG positivity despite treatment may indicate that there is a higher risk of relapse .
- Abnormal MRI and the presence of bands predicted the progression to MS , while sex and laterality had no influence. Patients with combined abnormal MRI and positive oligoclonal band had 27 the risk for conversion to MS compared to those without neither.
- Again what applies to NMO in adults seem to apply to children However , in children need to consider MOG ON rather than NMO .
- What is unique about the retina is that there is NO myelin and therefore you are looking in vivo at axons and studying the effects of many neurological diseases . MS now is now only one of several conditions that is being evaluated by MS but other neuro-denegerative diseases (Parkinson’s , Alzheimer’s , ALS) are being studies by OCT.
- Spectral domain thanks to its higher resolution and fast scan time has allowed us to look into greater details. We know no that almost all of these retinal layers are is either directly or indirectly involved in MS. Now we have EDI and Swept source OCT which provide even greater detail and depth of imaging .
- So again why OCT is useful in MS ? 1) Inflammatory changes in multiple sclerosis result in hyperintense fluid-attenuated inversion recovery (FLAIR) lesions on MRI and thickening of the INL. 2) We can assess retrograde trans-synaptic axonal degeneration is displayed as a model for secondary damage and consecutive atrophy of inner retinal layers after axonal injury in the optic pathway .
- It is known that there is ongoing axonal loss in MS whether patient had or did not have history of ON. This concurs with many post-mortem studies in which changes were found in the optic nerve and RNFL.
- Tha MAGNIMS group that initially advocated that ON lesion should be included among the diagnostic criteria but despite this recommendation and that inclusion of ON lesion increases sensitivity of diagnosis , long term data is not available as far specificity and whether these patients will eventually convert to MS. But even if they don’t then this perhaps suggest that these patients simply have a better prognosis . Therefore Standardization of VEP and OCT and more prospective studies are needed investigating the ability of these tests such as OCT to differentiate cases of MSON versus NMO and risk for developing MS .
- A very common situation in which a patient comes with history of prior acute loss of vision but the information is not well recalled and the data is not collected . With the recent MRI criteria , Involvement of the PVWM and SC may account for DIS and Gd Enhancement DIT , this DOES NOT apply for the ON if you have enhancing lesion of the optic nerve and PVMW lesions. YES : 1-Current MRI protocols are not useful in diagnosing asymptomatic optic nerve involvement 2- OCT is 1000 fold higher resolution than MRI. NO: There is insufficient evidence that inclusion of ON lesion diagnosed by either MRI , VEP or OCT would improve the performance of the current diagnostic criteria . The cost incurred by doing all these tests is not justified .
- This study looked at patients with MS and prior ON and showed that it’s not not much the absolute value (>1st percentile) from normal database that differentiated ON from NON but from but rather asymmetry the difference between the two eyes that is highly specific for unilateral ON lesion .
- 18% patients with MS in this study who fulfilled this criteria did not have history of optic neuritis but rather have sub-clinical optic neuropathy/atrophy and this was correlated with other visual function tests like contrast sensitivity . The study also concluded that inter-eye asymmetry in RNFL and OCT was a good index to detect unilateral ON lesion.
- Because these are two different diseases and have different treatments and traditional MS therapy can make NMO worse , it’s important to differentiate the two .
- The NMO-ON patient shows more severe thinning both in the RNFL and GCL. Notice that RNFL loss in MSON occurs usually in temporal quadrant (preferential involvement of small diameter axons in maculopapular bundle. However , in NMODS ON the RNFL loss is more diffuse ( more profound injury in arcuate and nasal fibres in NMOSD than in MS).
- The other thing is that thinning of GCL tend to be concentrated around the fovea (astrocytes rich in AQ4) while in MS it tends to be more evenly distributed in the macula , suggesting a retinal astrocytopathy (AQP4 receptor distribution)
- Multicenter study of 879 patients with CIS, RRMS and PMS followed after baseline OCT. This study showed that basline OCT can predict the risk of disability worsening and has a role in monitoring MS patients. So OCT can help you in knowing who will likely to progress and then perhaps adjust your therapy.
- Retrospective review of 402 patient on DMD. At least follow up of 1 year with aderence to DMD. Aggressive therapy with NAT slows the rate of GCIP, ONL, INL, and AMT thinning relative to more conventional MS treatments such as GA and the IFNs (particularly IFNSC). This support the role of OCT in monitoring the neuroprotective effects of DMD.
- Thickening of the Inner-nuclear layer (INL) is associated inflammatory disease activity and enlarging new T2-lesions. Clinical relapses associated with increased INL volume and eyes with prior ON Therefore INL may be a useful marker to assess clinical activity of disease and
- This is from the anti-LOINGO trial , which showed that remyelination (using VEP latency) did not diff significantly between the opicinumab and placebo groups in the ITT population at week 24. However , it did show that ganglion cell loss occurs as early as 2-4 weeks following ON and this is the probably the window of opportunity for treatment. You can extrapolate from this to other DMD in MS.
- This paper in JAMA just came out .
- MRI measure may not be as reliable to estimate brain atrophy and neurodegeneration .
- ACTiMus : will use OCT as a secondary outcome, measuring RNFL and macular volume to assess for improvement in the visual pathway . SPRINT-MS : OCT analysis of RNFL, GCIPL, and In this study d macular volume thickness as secondary outcome measures
- OCT is an excellent method to follow the effects of various neurological diseases by assessing neural tissue . Not only that it is allowing us to study the effects and pathophysiology of disease. And finally the invasive and the reproducibility of OCT makes it idea to use as an outcome measure in therapeutic trial.