Bilateral Retrobulbar Optic Neuritis Research Articles

CO178 Cardiovascular, Neurological, and Ocular Complications of COVID-19 Among Indian Patients – A Targeted Literature Review

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has had far-reaching health consequences, triggering off a chain of events involving multiple organs. The second wave of COVID-19 was worst in India and severely affected the people. We aimed to analyse the complications of COVID-19 on cardiovascular, neurological, and ocular system in Indian patients. The search was conducted in Embase platform using well-defined search strategy to identify studies reporting the complications of COVID-19 in Indian patients from inception of the database to 07 June 2022. Narrative/systematic reviews were excluded. A total of 1400 citations were retrieved; 38 studies met the inclusion criteria and included in analysis. Included studies were mostly case reports (n=28), retrospective observational (n=5), and prospective observational (n=5) studies. Patients were adults in most studies (97%). Eighteen studies reported ocular complications, with blurred vision, conjunctivitis, endophthalmitis reported by 16.6% of patients each, followed by loss of vision (11.1%). Case reports mentioned retinal vein occlusion, retinal artery occlusion, hyperemia, bilateral panuveitis, ophthalmoplegia, acute bilateral retrobulbar optic neuritis. Thirteen studies reported neurological complications, with headache (38%) being the most common complication, followed by fatigue, seizure and encephalitis (23% each). Case reports described complications such as confusion, depression, anxiety, psychosis, encephalopathy, polyradiculoneuropathy, facial palsy, global aphasia, acute cerebellitis, stroke, cerebral ataxia. Ten studies reported cardiovascular complications, and tachycardia (50%) was the most commonly reported complication, followed by acute coronary syndrome, cardiac injury, and bradycardia (20% each). Case reports mentioned hypertension, ischemic heart disease, pericardial effusion, cardiac tamponade, and congenital heart block as the cardiovascular complications. This review identified COVID-19 has caused significant complications on the ocular system, followed by neurological and cardiovascular organ system. Identification and reporting of these manifestations of SARS-CoV-2 will help in formulating the guidelines and protocol for early diagnosis and management.

Evans syndrome in child with sudden blindness

A 3-year-old girl presented with sudden onset of bilateral vision loss on waking up from sleep. There had been no associated eye pain, eye redness, fever or history of trauma in the days leading up to the presentation. She had been diagnosed with Evans syndrome at the age of 18 months and started on a regular dose of oral prednisolone under regular follow-up at the paediatric clinic. Upon presentation, her visual acuity was light perception bilaterally, with relative afferent pupillary defect in the right eye and sluggish pupils bilaterally. Bilateral fundus examination showed normal macula and pink optic discs without papilloedema. Other systemic examinations were unremarkable. The provisional diagnosis was severe bilateral retrobulbar optic neuritis, prompting further investigations to rule out infectious or vasculitic causes. Extensive investigations were carried out during admission including infective screenings of blood and urine, all of which were negative. A contrasted magnetic resonance image of the brain showed both orbital segments were swollen and appeared hyperintense, with involvement of the intracanalicular and intracranial segments, suggesting an inflammatory or demyelinating aetiology. A visual evoked potential test to rule out demyelination disease was also normal. As intravenous methylprednisolone treatment appeared to have a slow effect, the treatment was switched to intravenous gammaglobulin. The patient responded well to treatment, and her latest visual acuity assessment 1 month after presentation showed bilateral vision of 6/24. This is the first-ever Evans syndrome patient to be reported worldwide with bilateral optic nerve sterile inflammation.

The use of mesenchymal stem cells in optic nerve atrophy in patients with multiple sclerosis: A pilot study

Introduction. Cellular therapy of multiple sclerosis is currently considered to be one of the most promising treatment alternatives for this severe pathology of the nervous system. Materials and Methods. Two patients with relapsing-remitting multiple sclerosis (RRMS) complicated by partial optic nerve atrophy (ONA) caused by bilateral retrobulbar optic neuritis received treatment using autologous multipotent mesenchymal stem cells (MSCs). MSCs were derived by bone marrow aspiration/biopsy followed by isolation, culturing, and cryostorage. MSCs were administered in compliance with the developed protocol by short-term intravenous infusion of resuspension solution of 5% glucose supplemented with 10% autoserum at a dose of 2.0×10 6 /kg body weight in combination with local parabulbar administration of MSCs at a dose of 10×10 6 once per month during 4 months. The control group consisted of 2 patients of the same age with RRMS with partial ONA of the same severity who received background (metabolic and glucocorticoid) therapy. Results. Neurological and neuro-ophthalmological examination was carried out before and 6 months after treatment. The pilot study performed demonstrated that the elaborated protocol for MSC therapy is safe and, according to the preliminary data, therapy was characterized by moderate clinical effectiveness in incurable patients with RRMS and ONA. Conclusions. The findings make it possible to broaden the range of clinical studies focused on cellular therapy for multiple sclerosis.

Sequential bilateral retrobulbar optic neuritis in a young female

Optic neuritis (ON) is the demyelinating inflammation of the optic nerve head usually associated with multiple sclerosis. It is usually associated with sudden onset loss of vision with dyschromatopsia and retro-orbital pain. Atypical features for a demyelinating ON include the absence of pain, severe visual loss, progression of visual loss, pain for more than 2 weeks, and lack of recovery after 3 weeks. Atypical features in fundus examination include marked swelling of the nerve with retinal exudates, peripapillary hemorrhages and bilateral presentation, which may occur either simultaneously or sequentially. Atypical ON requires careful consideration and differentiation from demyelinating ON and ischemic optic neuropathy since the treatment is different. We describe a patient who presented with recurrent, sequential episode of visual loss over 2 years, without evidence of any additional neurological deficits, sarcoidosis, or systemic autoimmune disease. A diagnosis of chronic relapsing inflammatory optic neuropathy was made, and she was given intravenous steroids for 3 days, which improved the vision from hand movement close to face to 5/60 in the right eye. She was given immunosuppressants for 3 months, and oral steroids were gradually tapered. Her present vision is the right eye is 6/6 with normal intraocular pressure and color vision.

Fast Resolution of Bilateral Optic Neuritis Secondary to Multiple Sclerosis after Treatment with Glatiramer Acetate

Purpose: To report a patient with bilateral retro-bulbar optic neuritis (ON) secondary to multiple sclerosis (MS) who responded speedily to glatiramer acetate (GA) subcutaneous injections. Methods: Case report of a 34-year-old patient with multiple sclerosis that presented with bilateral optic neuritis, confirmed clinically and with visual fields. Concomitantly she had active neurological systemic symptoms that prompted the start of GA subcutaneously. Results: Clinical examination with pupillary reflexes, Ishihara test and visual fields pre and post injections revealed a quick recovery of the optic nerve function. Her neurological systemic symptoms improved significantly as well. Conclusion: ON secondary to MS is a frequent diagnosis in neuro-ophthalmology and it can be invalidating and distressing in an already disabled patient. GA is an immuno-modulator currently approved for use in patients with MS. We present a case of bilateral retro-bulbar ON that responded to the use of GA.

Bilateral Retrobulbar Optic Neuritis Caused by Varicella Zoster Virus in a Patient with AIDS.

AimsTo report on a case of bilateral retrobulbar optic neuritis in a patient with acquired immune deficiency syndrome (AIDS) caused by varicella-zoster virus (VZV); and to review the literature focusing on: cases reported, epidemiology, pathophysiology, diagnosis and treatment.Presentation of CaseA 38-year-old woman with AIDS presented with a 10-day history of progressive bilateral visual loss and ocular pain. She had bilateral dilated pupils with no light perception; the fundoscopic examination was normal. Facial herpes zoster lesions appeared on the second day of hospitalization Magnetic resonance imaging (MRI) findings were compatible with a bilateral optic neuritis; the cerebrospinal fluid (CSF) showed pleocytosis, increased proteins and a positive VZV-DNA PCR. She was treated with intravenous acyclovir and corticosteroids and was able, when discharged 2 weeks after admission, to carry out activities of daily living.DiscussionVZV retrobulbar optic neuritis has previously been reported in 12 patients with AIDS, more than half of the cases had concomitant herpes zoster and an associated retinopathy. A positive VZV-DNA in the CSF is indicative of VZV infection, initial use of intravenous acyclovir is recommended, and the concomitant use of corticosteroids would be a prudent choice; the duration of antiviral therapy remains undefined.ConclusionVZV retrobulbar optic neuritis in AIDS patients can occur with or without herpes zoster. It is a sight-threatening infectious and inflammatory process requiring the advice of specialists in infectious diseases, ophthalmology, neurology and viral microbiology.

Progressive outer retinal necrosis in an immunocompromised patient presenting with bilateral retrobulbar optic neuritis

Abstract Background: Progressive outer retinal necrosis (PORN) is a necrotizing chorioretinopathy caused by herpes simplex virus, varicella-zoster virus, or cytomegalovirus. Objective: To describe the clinical morphology of PORN presenting with asymmetrical isolated bilateral retrobulbar optic neuropathy. Method: The medical records of a 45-year-old human immunodeficiency virus infected patient presenting with bilateral visual loss at King Chulalongkorn Memorial Hospital were reviewed with respect for the privacy of patient. Result: Gradual visual loss progressed to no light perception in the right eye and 20/200 in the left eye within 1 month. The patient was initially diagnosed with retrobulbar optic neuritis in both eyes. The investigations included MRI, vitreous tapping, lumbar puncture, and serological testing. MRI elicited enhancement around both optic nerves, which suggested optic neuritis. Thereafter, multifocal areas of retinal necrosis developed with rapid progression and additional cutaneous zoster lesions were established. These findings led to a diagnosis of PORN. The patient was promptly treated with intravenous ganciclovir, anti-retroviral therapy, and vitrectomy with endophotocoagulation and silicone injection. Unfortunately, his visual prognosis in the left eye was still poor Conclusion: PORN was uncommonly present with bilateral isolated optic neuropathy before retinal lesions developed. Retrobulbar optic neuropathy from herpetic infection in immunocompromised patients should be considered despite a normal fundus at initial presentation. Early diagnosis and prompt intervention may preserve vision. This case demonstrates the importance of careful physical examination and follow up of retinal lesions.

Charles Bonnet Syndrome After Herpes Simplex Encephalitis

Visual impairment associated with Charles Bonnet syndrome is rarely reported in childhood. We describe a child who presented with visual hallucinations and postinfectious bilateral retrobulbar optic neuritis. The patient had undergone acyclovir therapy for 3 weeks because of herpes encephalitis. Four days after therapy was completed, he experienced visual impairment in both eyes. He manifested a bilateral decrease in visual acuity, with normal funduscopic findings. The patient experienced visual hallucinations for about 1 week, and then experienced total loss of vision. During his hallucinations, the patient did not exhibit behavioral changes or cognitive impairment. The visual hallucinations included unfamiliar children hiding under his bed, and he spoke to someone whom he did not know. Magnetic resonance imaging indicated bilateral optic nerve hyperintensity on T(2)-weighted and contrast-enhanced images. The patient received corticosteroid therapy for his retrobulbar optic neuritis, and his vision returned to normal after 1 month. Although rare, visual impairment can be associated with complex visual hallucinations indicative of Charles Bonnet syndrome.

Presumed cytomegalovirus‐associated retrobulbar optic neuritis in a patient after allogeneic stem cell transplantation

A case of cytomegalovirus (CMV)-associated bilateral retrobulbar optic neuritis (ON) following haploidentical hematopoietic stem cell transplantation (haplo-HSCT) is reported. Abrupt onset of bilateral decreased vision occurred in a 33-year-old man 7months after haplo-HSCT. His cerebrospinal fluid (CSF) demonstrated pleocytosis with an absence of leukemic cells. CMV DNA was detected in his blood and CSF sample. Neither encephalopathy nor retinopathy was found in this patient. He was diagnosed with bilateral retrobulbar ON. Although he was given enough antiviral treatment against CMV and immunosuppression with high-dose methylprednisolone, the patient's vision showed no improvement, and he has almost total bilateral blindness. This is the first report, to our knowledge, of CMV-associated bilateral retrobulbar ON in allogeneic stem cell transplantation.

PO20-WE-07 Bilateral retrobulbar optic neuritis in a case of Miller-Fisher syndrome

PO20-WE-07 Bilateral retrobulbar optic neuritis in a case of Miller-Fisher syndrome

Síndrome opticomedular como forma de presentación de un astrocitoma difuso

Spinal cord involvement is a rare presentation of grade II astrocytomas. Nevertheless, differentiation from inflammatory demyelinating diseases of the central nervous system can be challenging in some clinical situations. A patient with an optic-spinal syndrome due to a fibrillary astrocytoma is described. A 32 years-old man was admitted to the hospital because of a subacute spinal cord syndrome. Brain MRI showed no abnormalities, and spinal MRI disclosed a cervical cord lesion suggestive of myelitis. Cerebrospinal fluid analysis revealed oligoclonal bands. Clinical improvement was observed after corticosteroid treatment. Three months later, the patient presented with binocular vision loss. A bilateral retrobulbar optic neuritis was suspected, and corticosteroid therapy was administered again. A new MRI with spectroscopy revealed an infiltrative lesion involving the right frontal lobe, optic chiasm, internal capsule, brainstem and cervical spinal cord, which was suggestive of low-grade astrocytoma. Brain biopsy confirmed the diagnosis of diffuse fibrillary astrocytoma. Differential diagnosis between inflammatory and neoplastic lesions of the central nervous system requires close clinical-radiological follow-up. In this clinical situation, treatment response to corticosteroids and presence of oligoclonal bands in the cerebrospinal fluid may be not necessarily indicative of an inflammatory demyelinating process. Brain biopsy is often necessary for a definite diagnosis.

Bilateral Retrobulbar Optic Neuritis, Guillain-Barre Syndrome and Asymptomatic Central White Matter Lesions Following Adult Measles Infection

A 28-year-old woman presented with classic signs of measles and subsequently developed bilateral retro-bulbar optic neuritis and Guillain-Barré syndrome. Her radiographic and CSF findings were consistent with acute measles encephalitis. However, encephalopathy, such as behavioral changes and alteration in consciousness, was not presented. Improvements in the clinical, radiographic, and electrophysiological studies were observed during the steroid therapy. The overlap of CNS and PNS involvement as neurological complications of measles infection is very rare.

Human herpesvirus 6‐associated retrobulbar optic neuritis in an HIV‐infected patient: response to anti‐herpesvirus therapy and long‐term outcome

Like other herpesviruses, human herpesvirus 6 (HHV-6) can reactivate in immunocompromised patients. A case is described of an HIV-1-infected patient who developed bilateral retrobulbar optic neuritis associated with HHV-6 infection. A 59-year-old woman, infected with HIV for 18 years, interrupted antiretroviral treatment because of therapeutic failure and severe metabolic complications. She presented subsequently with blurred vision and ophthalmological examination showed visual loss due to optic neuritis. Her CD4+ count was 285 cells/mm(3) and her plasma HIV-1 RNA level was 5.5 log(10) copies (cp)/ml. Magnetic resonance imaging of the brain was normal. HHV-6 loads were 3.2 log cp/ml in cerebrospinal fluid (CSF) and 6.3 log cp/10(6) peripheral blood mononuclear cells. Combined intravenous treatment was started with foscarnet and ganciclovir then changed to cidofovir and long-term valganciclovir. Her ocular condition improved gradually despite little decrease of the HHV-6 load in the CSF. Salvage antiretroviral treatment was then administered, with marked immunological and virological responses, contributing to further progressive ocular improvement. HHV-6-related optic neuritis has not been described previously in HIV-infected patients. Anti-HHV-6 treatment improved the patient's vision, but immune restoration seems to remain essential for long-term recovery.

Endoskopowe leczenie chorych z wewnątrzczaszkowymi powikłaniami zapalenia zatok

Intracranial complications of sinusitis (cerebral, epidural, and subdural abscesses, meningitis, and dural sinus thrombophlebitis) remain a challenging and current topic. Although they are nowadays relatively rare, prompt recognition of these disease states is important to prevent permanent neurological deficit or fatality. Infection may spread hematogenously or by direct extension. Patients with complications require surgery to remove the focus of infection from the sinuses and drain the abscess. Recently, endoscopic frontal and sphenoid sinus surgery has emerged as the preferred technique for the treatment of the most advanced and complicated chronic sinusitis. Records of 7 patients aged from 13 to 65 (mean 30.6) years treated in our department for intracranial complications between January 2002 and September 2006 were analysed retrospectively. The diagnosis of meningitis was established in 2 patients, in one case with accompanying bilateral oculomotor nerve palsy. Cavernous sinus thrombosis, frontal abscess with hemiplegia, cerebral oedema, bilateral oculomotor nerve palsy and retrobulbar optic nerve neuritis with blindness was diagnosed each in one individual. 5 endoscopic bilateral frontosphenoethmoidectomies and 2 endoscopic sphenoethmoidectomies were performed. In one case a frontosphenoethmoidectomy was combined with craniotomy. All preoperative symptoms subsided in 4 operated individuals. Vision improved in the patient with bilateral retrobulbar optic nerve neuritis. In patients with hemiplegia and bilateral oculomotor nerve palsy the symptoms persisted. No complications of the surgery were observed. Surgical treatment of the focus of infection in the sinuses can be accomplished endoscopically via an intranasal approach with less morbidity, easy identification of anatomical structures, physiological drainage of the sinuses and superior cosmetic effects.

Varicella-zoster Virus Retrobulbar Optic Neuritis in a Patient With Human Immunodeficiency Virus

To determine the cause of bilateral retrobulbar optic neuritis followed by progressive outer retinal necrosis in a patient with human immunodeficiency virus (HIV). Extensive ophthalmologic, neurologic, infectious disease, rheumatologic, and radiologic examinations were performed. Cerebrospinal fluid samples taken after the onset of bilateral retrobulbar optic neuritis and before the development of clinical progressive outer retinal necrosis disclosed varicella-zoster virus from polymerase chain reaction and viral culture. Ophthalmologists and neurologists should consider varicella-zoster virus optic neuritis as a potential precursor of progressive outer retinal necrosis and as a cause of retrobulbar optic neuritis in patients infected with HIV.

Bilateral Optic Neuritis Originating in a Single Chiasmal Lesion

A case of bilateral retrobulbar optic neuritis with profound visual loss is described. Magnetic resonance imaging (MRI) with fat-saturation suppression and gadolinium enhancement done 15 days after the onset of symptoms demonstrated bilateral posterior optic nerve disease in a pattern similar to that seen in previously reported cases. However, subsequent retrospective review of an MRI study done at a different hospital during the first week of disease demonstrated a single focus of gadolinium enhancement within the body of the chiasm. This observation suggests that bilateral demyelination of the posterior optic nerves may begin as a single focus of chiasmal disease that then spreads to involve the proximal portions of the optic nerves.

Acquired Color Vision Defects in Retrobulbar Neuritis

We used the Farnsworth-Munsell 100 Hue Test to study the incidence of acquired color vision defects in 16 patients with unilateral and and seven patients with bilateral retrobulbar optic neuritis whose visual acuity had recovered to 6/12 (20/40) or better. We recorded the visual-evoked response to a pattern stimulus on the same day. All 30 affected eyes showed an excessive number of errors on Farnsworth-Munsell 100 Hue testing. The number of errors increased with greater residual optic nerve damage. One false-positive and two false-negative visual-evoked responses were found.