Optic Neuritis and Imbalance

[kag]

CAN AN OPTHAMOLOGIST RATHER THAN A NEURO OPTHAMOLOGIST HANDLE A CASE OF OPTIC NEURITIS?  AND IF I GO, WILL THEY SEND ME BACK TO THE NEURO OPTHAMOLOGIST?  I APPRECIATE ANY THOUGHTS?

[John C Hagan]

You have stumped both a neurologist and a neuro-ophthalmologist that have examined you and looked at all your data and tests first hand. I believe I have gone as far as I can go in this format. I wish you good luck and if a definitive diagnosis is established let us know.

JCH III MD

[kag]

DEAR DOCTOR,

THANK YOU FOR YOUR RESPONSE.  MY NEURO-OPTHA IS GOING TO SEND THE REPORT TO THE NEUROLOGIST AND HE MAY CHANGE HIS MIND REGARDING THE SPINAL TAP.  SINCE MY NEUROLOGIST IS UNAVAILABLE UNTIL AFTER THANKSGIVING, I TRULY DON'T KNOW WHAT TO DO.   I SENSE MAYBE THE OPTHA NEURO IS TRYING TO PUT A NAME TO MY ISSUES AND MOVE FROM THERE, BUT DOWN THE ROAD.  ANY THOUGHTS PLEASE ??

I AM GRATEFUL.

[John C Hagan III, MD, FACS, FAAO]

Your case warrents continued follow up with your neurologist and neuro-ophthalmologist. I'm very concerned that there is more than one problem going on. Optic nerve drusen will NOT cause pain, pressure, dizziness, vertigo or those types of symptoms.  

It's possible your Eye MD saw some ON drusen on the MRI that the radiologist might not have seen.  ON drusen rarely cause visual problems. In a very large practice I only have one or two patients that have had their vision affected to where they can tell.

Hopefully your two doctors can confir and make a joint recommendation about a spinal tap. Based on you symptoms at present I would say you DO need one and would side with the neurologistl.

JCH III MD

[kag]

I AM SORRY.  I FAILED TO MENTION THAT UPON EXAMINATION OF MY DILATED EYES, THE NEURO OPTHA SAW A SLIGHT FULLNESS IN MY RIGHT OPTIC NERVE THAT HAD NOT BEEN THERE BEFORE.  

[kag]

DEAR DOCTOR,  

I WENT ON TO THE NEW OPTHA-NEURO.  HE HAD ORDERED A CT ORBITS WITHOUT/WITH CONTRAST & CT SCAN OF HEAD WITHOUT/WITH CONTRAST. BOTH IMPRESSIONS: NORMAL.
HE THEN LOOKED AT THE FILMS AND SAID HE SAW DRUSEN'S.  DOES DRUSEN'S ONLY SHOW UP ON THE FILM ITSELF AND NOT IN THE REPORT?  HE TOLD ME TO USE TEAR TYPE DROPS EVERY HOUR.  I CONTINUE TO HAVE EYE PAIN AND PRESSURE THAT IS ONLY HELPED SOME BY USING CELEBREX.  I CONTINUE TO HAVE SLIGHT IMBALANCE WHEN I AM IN THE PROCESS OF LAYING DOWN OR CASTING MY EYES DOWN. UNSURE IF THIS IS TRUE IMBALANCE OR BECAUSE MY EYE FEELS STRANGE.  I DID HAVE A VISUAL DEFECT BOTH TIMES I WAS TESTED.  ON 11/28 THE VFD WILL BE RAN AGAIN AND THEN I WILL MEET WITH THE NEURO OPTHA THE FIRST WEEK OF DECEMBER.  

DOES DRUSEN'S USUALLY MANIFEST AS MY SYMPTOMS DID?  IN THE BEGINNING WEEKS I  HAD PAIN IN THE EYE, BLURRED VISION, VERTIGO TYPE FEELING AND NOW ONGOING PRESSURE/PAIN TO TOUCH IN EYE?  WHAT ELSE CAN HAPPEN WITH DRUSEN'S AS TIME GOES ON?  SHOULD I BE CONCERNED OR DO I FIT AS A TRUE DRUSEN'S PATIENT.  

MY NEUROLOGIST DOES NOT SEE ME UNTIL END OF NOVEMBER AS HE IS OUT WITH PNEUMONIA.  HE HAD SUGGESTED A SPINAL TAP, BUT THE OPTHA NEURO SAID NOT NECESSARY.  

I DEEPLY APPRECIATE YOUR WISDOM AND TIME.

[kag]

I

[John C Hagan III, MD, FACS, FAAO]

You will have a much better picture when your tests are back. The spinal tap is primarily to determine if the spinal fluid pressure is too high. Hopefully that test won't be necessary.

Drusen of the optic nerve usually do not cause visual loss that is percepitable to the patient. I have several patients that the optic nerve drusen has causes some damage to peripheral vision.

If that is you your Dx then the neuro-ophthalmologist will discuss in more detail.

Use Google IMAGE and look up "optic nerve drusen" to see what they look like.

JCH III MD

[kag]

DEAR DOCTOR,

I HAD THE SPINAL MRI,ECHO,CARTOID US, AND MRA YESTERDAY AND NO RESULTS AS OF YET.  I WENT ON TO ANOTHER NEURO-OPTHA-SURGEON TODAY.  HE SAID THE LEFT OPTIC NERVE REMAINS SWOLLEN WITH FULLNESS IN THE RIGHT OPTIC NERVE.  HE IS SENDING ME FOR A CAT SCAN OF ORBITS WITH CONTRAST TODAY TO SEE IF IT IS DRUSENS.  IF NOT, I WILL BE HAVING A SPINAL TAP.  GIVEN THE NEGATIVE RESULTS OF BRAIN MRI.VEP, BLOODWORK, MRA, WHAT POSSIBLITIES AM I LOOKING AT FOR A DIAGNOSIS FROM THE CSF?  IF IT IS DRUSEN'S WHAT WILL MY PROGNOSIS BE FOR VISION? THANK YOU VERY MUCH FOR YOUR VALUABLE TIME.  

[John C Hagan III, MD, FACS, FAAO]

A neuro-ophthalmologist is not a retina specialist. All retina speciialists can do OCT test now, some neuro-ophthalmologists can.  See if either of the neuro-ophthalmologists can do optic nerve OCTs. if not ask them to send you to a retina EYE  MD that can.

The cause of the rapid spinal fluid production is unknow. The condition (also known as Benign intracranial hypertension) is usually successfully treated with Diamox which shows down production. In severe cases an operation that cuts a hole in the optic nerve cover to drain it into the eye socket is done (optic nerve fenestration).

JCH III MD

[kag]

I AM GRATEFUL FOR YOUR QUICK AND DETAILED REPLY.  FORGIVE ME, BUT IS A NEURO-OPTHAMOLOGIST A RETINAL SPECIALIST?  IF NOT, SHOULD I SEE A RETINAL SPECIALIST INSTEAD OF THE NEURO-OPTHAMOLOGIST?  IF IT IS NOT DRUSEN'S, IT SEEMS I SHOULD HAVE THE SPINAL TAP.  

WHAT COULD CAUSE THE SPINAL FLUID TO BE PRODUCED TOO FAST?  

THANK YOU AGAIN.  

[John C Hagan III, MD, FACS, FAAO]

The first ophthalmologist thought you did not true swelling of the optic nerve (papilledema) and the cause was buried crystals in the optic nerve called drusen of the optic nerve.  The neurologist apparently thinks you have true swelling papilledema which can be caused by brain tumors or the spinal fluid being produced too fast.

I would see the second neuroolphthalmologist quickly as if you do have optic nerve drusen you don't need all those tests.

A new test Optic Nerve OCT or ON ultrasound (both usually done by retinal specialists) can often visualize the optic nerve drusen even when they can't be seen. I would call the first neuro ophtalmologist, tell him/her what you're scheduled for by the neurologist.

It is often very hard to tell these two conditions appart.

As him/her about an optic nerve OCT or ultrasound.

JCH III MD

[kag]

DEAR DOCTOR,

THANK YOU AGAIN FOR ALL YOUR HELP. I VISITED A NEUROLOGIST THIS WEEK AND HE HAS ORDERED AN US OF THE CARTOID, AN UPPER SPINE MRI, A MRA OF HEAD, AND AN ECHOCARDIOGRAM.  HE FELT I SHOULD PROBLEY HAVE CSF IN A FEW WEEKS IF ALL COMES BACK NEGATIVE. HE DISAGREED WITH THE OPTHA NEURO REGARDING DRUSEN.  

I HAVE MADE A APPT. FOR A SECOND OPINION AT AN OPTHA NEURO ON WEDNESDAY.

MY CURRENT NEURO OPTHA GAVE THE FOLLOWING REPORT A FEW DAYS BACK.  COULD YOU PLEASE EXPLAIN TO ME IN LAYMEN'S LANGUAGE.  I AM VERY CONFUSED REGARDING THE CARE I NEED. I CONTINUE TO HAVE EYEBALL PAIN IN THE AFFECTED EYE.  

DILATED OPTHA FOUND BLURRED DISC MARGINS, A 0.0. CUP, ELEVATED CENTRAL PAPILLAE, & IRREGULAR DISC MARGINS. THIS HAS NOT CHANGED SINCE FIRST LOOK ON 9/4 W/O OPTIC NEUROPATHY SUPERVENING.  THIS DISC HAS THE APPEARANCE OF PSEUDOPAPILLEDEMA DUE TO OPTIC DISC DRUSEN, IT IS NOT IMPOSSIBLE FOR IT'S PRESENCE.  AS TO THE TIGHT DISC OS, IT IS CONSISTENT WITH THE PREDISPOSITION TO ISCHEMIC OPTIC NEUROPATHY, BUT IS IS ALSO QUITE CHARACTERISTIC  OF THE PSEUDOPAPILLEDEMA APPEARANCE OF OPTIC DISC DRUSEN.  ABSENT ATROPHY TODAY, I THINK THIS WILL BE MY PRIMARY DIAGNOSIS.  

THANK YOU FOR YOUR WISDOM AND GUIDANCE, DOCTOR.  

[John C Hagan III, MD, FACS, FAAO]

While medicine is not exactly a commodity it is a fair assumption that both individuals are well trained and experienced. There are advantages to going to a near-by specialist and your present Eye MD may have well worked with the near-by neuro-ophthalmologist.

I really don't think you can make a wrong decision. I would go with the closer physician.

JCH III MD

[kag]

Thank you.  I have looked and found two specialist. One is near my current specialist and one is at a learning hospital about an hour away in Tampa.  Which would be better versed in your opinion?

I am grateful...

[John C Hagan III, MD, FACS, FAAO]

Yes go to the website of the American Academy of Ophthalmology  www.aao.org and use the Find An Eye MD feature to locate one near you.

JCH III MD

[kag]

THANK YOU FOR YOUR KINDNESS. I CALLED A FEW OPTHAMOLOGISTS IN MY AREA TO ASK FOR NEURO-OPTHAMOLOGIST AND THEY TOLD ME THAT THEY ONLY KNOW OF THE ONE I GO TO.  IS THERE ANY WAY TO LOCATE ONE IN MY AREA VIA THE INTERNET?  I DID MAKE AN APPOINTMENT WITH A NEUROLOGIST NEXT WEEK.  I AM GRATEFUL.

[John C Hagan III, MD, FACS, FAAO]

I would suggest either seeing a second neuro-ophthalmologist for a second opinion or going to a neurologist.

It may be that your present neuro-ophthalmologist thinks that you have "pseudo-papilledema" which is a false swelling of the eye. What makes me think this is the statement that you may have had this from birth. If this is the case you may need an optic nerve OCT or sonogram to determine if you have buried drusen which is a common cause of false swelling.

JCH III MD

[kag]

THANK YOU FOR YOUR KIND REPLY.  SINCE MY NEURO-OPTHAMOLOGIST SAID TO COME BACK IN SIX WEEKS AND MY EYE IS STILL HURTING, WOULD IT BE WISE TO SEE A NEUROLOGIST ON MY OWN?  THE NEURO-OPTHAMOLOGIST SAID THAT HE IS JUST THINKING I WAS BORN WITH THIS AND HAVE TO LIVE WITH IT THIS PAST APPOINTMENT. PRIOR TO THAT HE WAS TALKING OF SENDING ME TO A NEUROLOGIST, BUT HAS NOW SENT A REPORT TO MY PRIMARY SAYING NOT TO GO.  YET THE NERVE IS STILL SWOLLEN AFTER TWO MONTHS AND NOT MUCH HAS CHANGED IN TWO MONTHS.  I DID NOT GO ON ANTIBIOTICS OR ORAL STEROIDS UNTIL TWO WEEKS AGO WHEN THE ENT WAS SURPRISED THAT I HAD NOT BEEN TREATED AND PRESCRIBED THE DRUGS.  I AM BESIDE MYSELF WITH NOT KNOWING WHAT TO DO ADN WORRYING THAT SOMETHING ELSE IS WRONG.  I AM 46 WITH TEENS AT HOME.  ANY WISDOM IS GREATLY APPRECIATED.

[John C Hagan III, MD, FACS, FAAO]

It will vary. When I was doing general ophthalmology I treated optic neuritis often in conjuction with the patients family doctor or internist. The treatment usually involves intravenous steroid for three days and oral steroid for a week.  

Since I joined a group with a neuro-ophthalmologist I send patients with ON to him.

Some opthalmologists make the diagnosis but don't do the treatment usually sending the patient to a neurologist who besides treating often examines the patient for signs of multiple sclerosis and other things in the body that can cause ON.

JCH III MD