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Bilateral papillitis associated with chiasmal optic neuritis
Taiwan Journal of Ophthalmology 2 (2012) 112–113
Contents lists available at SciVerse ScienceDirect
Taiwan Journal of Ophthalmology journal homepage: www.e-tjo.com
Letter to the Editor
Bilateral papillitis associated with chiasmal optic neuritis Dear Editor We read with great interest the article entitled “Chiasmal optic neuritis: A report of three cases” by Shih-Yun Lee, An-Guor Wang,
and May-Yung Yen.1 The authors have described the clinical presentations and the visual outcome of three cases of chiasmal optic neuritis. All three cases are female, with long term multiple sclerosis and previous episodes of unilateral or bilateral optic
Fig. 1. Fundus examination showed right (A) and left (B) papilledema before the initiation of methylprednisolone treatment. MRI showed abnormal high signal change of optic chiasm on coronal (D) FLAIR imaging; and abnormal enhancement of bilateral posterior intraorbital optic nerves (C). Visual field examination (Octopus static perimetry) with 30 degree low vision program five days after methylprednisolone treatment (E and F). 2211-5056/$ – see front matter Copyright Ó 2012, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.tjo.2012.05.003
Letter to the Editor / Taiwan Journal of Ophthalmology 2 (2012) 112–113
neuritis. Also, in all of these cases, optic neuritis was presented as retrobulbar optic neuritis, without apparent inflammatory changes in the optic disc on fundus examination. Recently, we encountered a case with bilateral optic neuritis associated with chiasmal involvement. In contrast to the above cases, our patient was a young male, without any history of systemic disease, including multiple sclerosis, who presented with bilateral papillitis; it was his first episode of attack. We believe that the presentation of our case may supplement the above cases and help to elucidate the variable clinical characteristics of chiasmal optic neuritis. Case report A 25-year-old male was seen after progressive, bilateral visual loss in 2 weeks. He had light perception in his right eye and doubtful light perception in his left eye. Apart from mild cough with fever for 1 day, he denied any systemic disease or trauma event prior to this episode. The patient’s initial complaint was mild pain during eye movement and periocular fullness sensation in the morning for 2 to 3 days. Visual disturbance first took place in his right eye, then in his left eye in 1 week. Fundus examination showed bilateral disc edema and hemorrhage (Figs. 1A and 1B). There were no significant findings on physical or neurological examination. Under the impression of bilateral optic neuritis, the patient was treated with intravenous methylprednisolone 250 mg every 6 hours for 3 days, followed by oral prednisolone for another 2 weeks. Magnetic resonance imaging (MRI) showed an abnormal high signal change in the optic chiasm on coronal FLAIR imaging and abnormal enhancement of bilateral posterior intraorbital optic nerves and sheath, more on the left (Figs. 1C and 1D). Visual field examination 5 days after the initiation of corticosteroid treatment revealed a near total scotoma, with slight sparing of the nasal field in the right eye, and a temporal hemianopsia with less nasal involvement in the left eye (Figs. 1E and 1F). After a full course of corticosteroid treatment, disc swelling and hemorrhage subsided gradually. The visual acuity improved to 6/12 in his right eye and 6/30 in his left eye. A significant improvement in visual field examination was also noted. Laboratory examination, such as anti-nuclear antibody (ANA), anti-ds DNA, anti-cardiolipin IgG, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatic arthritis (RA), C3, C4, vitamin-B12, and folate were checked and were within the normal range. Serologic tests for syphilis (rapid plasma reagin) and human immunodeficiency virus (HIV) were negative. Only mild leukocytosis was noted, yet no clinical evidence of infection was found. The initial diagnosis of our patient was thought to be bilateral optic neuritis. However, the subsequent visual field and MRI examinations revealed the existence of chiasmal optic neuritis. Although bilateral involvement may comprise up to 16.4% (Singapore)2 and 34.9% (Taiwan)3 in idiopathic optic neuritis of Asian patients, the association of chiasmal optic neuritis with bilateral optic neuritis has rarely been reported in the literature. By a sequential examination of MRI in a patient with idiopathic bilateral optic neuritis,
113
Soltau and Hart found a chiasmal inflammation with asymmetric bilateral optic nerve and tract involvement.4 They hypothesized that in these cases, the bilateral optic neuritis may originate from the chiasmal portion, with extension of inflammation along the bilateral optic nerves. In an 8-year-old girl with bilateral papillitis, Beiran et al also identified a chiasmal involvement in the MRI examination.5 Like our case, both of those patients also suffered initial profound visual impairment, but with good recovery after intravenous corticosteroid pulse therapy, followed by oral prednisolone. In conclusion, the addition of this case further supports, that in patients with sequential or simultaneous bilateral optic neuritis, chiasmal optic neuritis must be taken into consideration; as suggested by the authors, detailed MRI examination of the optic chiasma is mandatory for an accurate diagnosis. References 1. Lee SY, Wang AG, Yen MY. Chiasmal optic neuritis: a report of three cases. Taiwan J Ophthalmol 2012;2:68–72. 2. Lim SA, Goh KY, Tow S, Fu E, Wong TY, Seah A, et al. Optic neuritis in Singapore. Singapore Med J 2008;49:667–71. 3. Lin YC, Yen MY, Hsu WM, Lee HC, Wang AG. Low conversion rate to multiple sclerosis in idiopathic optic neuritis patients in Taiwan. Jpn J Ophthalmol 2006;50: 170–5. 4. Soltau JB, Hart Jr WM. Bilateral optic neuritis originating in a single chiasmal lesion. A case report. J Neuroophthalmol 1996;16:9–13. 5. Beiran I, Krasnitz I, Zimhoni-Eibsitz M, Gelfand YA, Miller B. Paediatric chiasmal neuritis–typical of post-Epstein-Barr virus infection? Acta Ophthalmol Scand 2000;78:226–7.
Tze-Yi Chan Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan Yu-Chi Lin Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan Cheng-Kuo Cheng* Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan College of Medicine, National Taiwan University, Taipei, Taiwan * Corresponding author. Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, 95, Wen-Chang Road, Shih-Lin District, Taipei 11101, Taiwan. E-mail address: [email protected] 6 February 2012 Available online 17 July 2012
Contents lists available at SciVerse ScienceDirect
Taiwan Journal of Ophthalmology journal homepage: www.e-tjo.com
Letter to the Editor
Bilateral papillitis associated with chiasmal optic neuritis Dear Editor We read with great interest the article entitled “Chiasmal optic neuritis: A report of three cases” by Shih-Yun Lee, An-Guor Wang,
and May-Yung Yen.1 The authors have described the clinical presentations and the visual outcome of three cases of chiasmal optic neuritis. All three cases are female, with long term multiple sclerosis and previous episodes of unilateral or bilateral optic
Fig. 1. Fundus examination showed right (A) and left (B) papilledema before the initiation of methylprednisolone treatment. MRI showed abnormal high signal change of optic chiasm on coronal (D) FLAIR imaging; and abnormal enhancement of bilateral posterior intraorbital optic nerves (C). Visual field examination (Octopus static perimetry) with 30 degree low vision program five days after methylprednisolone treatment (E and F). 2211-5056/$ – see front matter Copyright Ó 2012, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.tjo.2012.05.003
Letter to the Editor / Taiwan Journal of Ophthalmology 2 (2012) 112–113
neuritis. Also, in all of these cases, optic neuritis was presented as retrobulbar optic neuritis, without apparent inflammatory changes in the optic disc on fundus examination. Recently, we encountered a case with bilateral optic neuritis associated with chiasmal involvement. In contrast to the above cases, our patient was a young male, without any history of systemic disease, including multiple sclerosis, who presented with bilateral papillitis; it was his first episode of attack. We believe that the presentation of our case may supplement the above cases and help to elucidate the variable clinical characteristics of chiasmal optic neuritis. Case report A 25-year-old male was seen after progressive, bilateral visual loss in 2 weeks. He had light perception in his right eye and doubtful light perception in his left eye. Apart from mild cough with fever for 1 day, he denied any systemic disease or trauma event prior to this episode. The patient’s initial complaint was mild pain during eye movement and periocular fullness sensation in the morning for 2 to 3 days. Visual disturbance first took place in his right eye, then in his left eye in 1 week. Fundus examination showed bilateral disc edema and hemorrhage (Figs. 1A and 1B). There were no significant findings on physical or neurological examination. Under the impression of bilateral optic neuritis, the patient was treated with intravenous methylprednisolone 250 mg every 6 hours for 3 days, followed by oral prednisolone for another 2 weeks. Magnetic resonance imaging (MRI) showed an abnormal high signal change in the optic chiasm on coronal FLAIR imaging and abnormal enhancement of bilateral posterior intraorbital optic nerves and sheath, more on the left (Figs. 1C and 1D). Visual field examination 5 days after the initiation of corticosteroid treatment revealed a near total scotoma, with slight sparing of the nasal field in the right eye, and a temporal hemianopsia with less nasal involvement in the left eye (Figs. 1E and 1F). After a full course of corticosteroid treatment, disc swelling and hemorrhage subsided gradually. The visual acuity improved to 6/12 in his right eye and 6/30 in his left eye. A significant improvement in visual field examination was also noted. Laboratory examination, such as anti-nuclear antibody (ANA), anti-ds DNA, anti-cardiolipin IgG, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatic arthritis (RA), C3, C4, vitamin-B12, and folate were checked and were within the normal range. Serologic tests for syphilis (rapid plasma reagin) and human immunodeficiency virus (HIV) were negative. Only mild leukocytosis was noted, yet no clinical evidence of infection was found. The initial diagnosis of our patient was thought to be bilateral optic neuritis. However, the subsequent visual field and MRI examinations revealed the existence of chiasmal optic neuritis. Although bilateral involvement may comprise up to 16.4% (Singapore)2 and 34.9% (Taiwan)3 in idiopathic optic neuritis of Asian patients, the association of chiasmal optic neuritis with bilateral optic neuritis has rarely been reported in the literature. By a sequential examination of MRI in a patient with idiopathic bilateral optic neuritis,
113
Soltau and Hart found a chiasmal inflammation with asymmetric bilateral optic nerve and tract involvement.4 They hypothesized that in these cases, the bilateral optic neuritis may originate from the chiasmal portion, with extension of inflammation along the bilateral optic nerves. In an 8-year-old girl with bilateral papillitis, Beiran et al also identified a chiasmal involvement in the MRI examination.5 Like our case, both of those patients also suffered initial profound visual impairment, but with good recovery after intravenous corticosteroid pulse therapy, followed by oral prednisolone. In conclusion, the addition of this case further supports, that in patients with sequential or simultaneous bilateral optic neuritis, chiasmal optic neuritis must be taken into consideration; as suggested by the authors, detailed MRI examination of the optic chiasma is mandatory for an accurate diagnosis. References 1. Lee SY, Wang AG, Yen MY. Chiasmal optic neuritis: a report of three cases. Taiwan J Ophthalmol 2012;2:68–72. 2. Lim SA, Goh KY, Tow S, Fu E, Wong TY, Seah A, et al. Optic neuritis in Singapore. Singapore Med J 2008;49:667–71. 3. Lin YC, Yen MY, Hsu WM, Lee HC, Wang AG. Low conversion rate to multiple sclerosis in idiopathic optic neuritis patients in Taiwan. Jpn J Ophthalmol 2006;50: 170–5. 4. Soltau JB, Hart Jr WM. Bilateral optic neuritis originating in a single chiasmal lesion. A case report. J Neuroophthalmol 1996;16:9–13. 5. Beiran I, Krasnitz I, Zimhoni-Eibsitz M, Gelfand YA, Miller B. Paediatric chiasmal neuritis–typical of post-Epstein-Barr virus infection? Acta Ophthalmol Scand 2000;78:226–7.
Tze-Yi Chan Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan Yu-Chi Lin Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan Cheng-Kuo Cheng* Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan College of Medicine, National Taiwan University, Taipei, Taiwan * Corresponding author. Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, 95, Wen-Chang Road, Shih-Lin District, Taipei 11101, Taiwan. E-mail address: [email protected] 6 February 2012 Available online 17 July 2012