Questionable Optic Neuritis

[6-paq]

I'm a 45 yo female.  About 1.5 years ago, I had a brain MRI due to constant headaches.   Found a 1.5 cm x 0.9 cm non-enhancing periventricular lesion.  My neurologist suspects MS based on lesion location.   I do have some symptoms that could be related to MS, but after testing, have been explained by other causes at this point.   My spinal tap, evoked potentials, reflexes, etc. have all been normal in the past 1.5 years.   A repeat brain MRI 13 months after the first is stable.

On a recent "check-up" visit with my ophthalmologist, my right eye showed a pale optic nerve.   My ophthal could not diagnose optic neuritis as I've had 2 normal vision field tests (last was 2 months prior to exam), stable visual acuity of 20/20, a normal VEP (taken in July 2007), and I have had no symptoms of ON.

My ophthal said that it was good that my VF is normal and that my vision is 20/20.   He said it could be an "overexposed picture" of the right optic nerve and to come back in 6 months for my usual follow-up.  

I have had no pain, no reduction of peripheral vision, nor blurred vision other than the "normal" effects of aging (farsighted and need glasses to read).   I have no visual effects due to heat.  Due to an absence of symptoms and normal testing, I was surprised at the pale optic nerve.

I'm questioning my ophthalmologist's possible explanation of an "over-exposed" photo.  The tech did have trouble getting a picture of my left eye, but it is my right eye that is "pale".

Is it possible to have ON without symptoms and normal VF and visual acuity?   It is possible to have an "over-exposed" photo?  If so, shouldn't my ophthal have repeated the photo of the eye in question?  Is there other Sx of ON during exam that my ophthal would have seen?   If I'm having no symptoms of optic neuritis, is it "safe" to wait an additional 6 months for follow-up?


Thank you

[6-paq]

Thank you for your quick response.  Having spent the last 1.5 years under a "possible MS" diagnosis, I'm not happy about being told that I have "possible optic neuritis" and have to wait another 6 months for another look.  I would assume that there would be no question in diagnosing ON.

I am aware that this could be another piece of the puzzle. I'm just not understanding why he didn't take another picture of the optic nerve if there is any question.      

I'm assuming that nothing could confirm it via physical examination.  Perhaps another VEP would be in order.

Thank you again for your time.

[Michael J Kutryb, MD]

Pigment dispersion syndrome can cause glaucoma with elevated intraocular pressure and optic nerve cupping and damage.  You would not expect damage to the optic nerve in pigment dispersion syndrome unless there was evidence of elevated pressure at least at some point in time.  Just speaking in general terms.  Now regarding the questionably pale optic nerve - it might have been better for the doctor to say nothing rather that leave this huge open ended situation.  Why leave it like that with you wondering what it really is.  Basically he can take another picture and the both of you can look at it and have some sort of conclusion as to whether the one nerve is pale or not.   What if it did look pale?  You have already had the huge workup and still loooking for MS.  Perhaps it is just one more piece of the puzzle possibly supporting a potential diagnosis of MS?  Maybe yes, maybe no.

Michael Kutryb, MD

[6-paq]

I also wanted to add that my ophthalmologist diagnosed me with Pigment Dispersion Syndrome previously.   Could this have anything to do with the pale optic nerve?