Old cases of optic neuritis?

Hey guys,

Can old incidences of optic neuritis be detected on exam if you are no longer feeling any symptoms?  I assume the damage can be seen even if there has been some improvement of symptoms, but I just wanted to see.

[Eyesnlegs]

Each time I have an eye exam the first thing that is said is - you have a very pale lens but that is to be expected as you have had ON.

It also frequently results in an abnormal reading on a VEP test as mine did too.

I have had ON twice and it has left me with some real vision issues but all that can be seen by anyone examining me is a pale lens.



Hope this helps

Pat

[jdhecaj]

I have had ON in each eye. The first one was 20 years ago confirmed and treated by an ophthalmologist. It healed completely.It's my stronger eye. I had the second case about 20 years later after I was diagnosed with MS. I told the neuro, I had ON again and it is happening just like I remembered it happening 20 years ago. She just ordered IV steroids over the phone & didn't require an office visit.

In the 20 years since the first ON that was diagnosed & treated by an ophthalmologist, no optometrist or ophthalmologist has noticed anything different about my lenses. And when I told them I had ON in the past, they looked at them very closely.

The neuro who diagnosed me also looked at that eye and charted that it wasn't pale but it was peculiarly shaped, like a cat eye. I think that just how people are anatomically different and the differences are ok & normal. Like I have big feet. I don't like that but it is normal. Apparently my optic lens is peculiarly shaped & it benefited me.

The second ON that was about 4 years ago, has not healed fully and is "blurry" some days. On eye exams they write "vision not correctable by lenses", last eye test the  wrote there was some peripheral loss in that eye. I'd like to get it rechecked before my next neuro appointment to see if it got back to normal, of course it has become normal for me so I really need an eye test to determine what it is.
During the eye exam, the optomotrist didn't say it was pale.

So for me there was no indication that I had ON. Just poor vision in one eye. Great vision in the other eye.

[essdipity]

If there is damage to an optic nerve it will still be there. The trouble is that very often the damage is not detectable by an eye exam, because the lesion is further back on the nerve.

Sometimes other testing can help. For instance, if a VEP is abnormal, this is likely an indicator of ON, even when there are no eye symptoms. A newer test, the OCT, can tell whether the nerve is damaged as well. Quix wrote extensively about this recently, so you may want to do a quick Search This Community to find it. As I understand it, the OCT is not used to diagnosed MS, but it can give important info about how far MS has progressed.

It would be great if the OCT could replace MRI, at least for some purposes. It's quick and much much cheaper.

Well, I hope you now have a few more leads to look into. There are good resources in your area which I do hope you'll pursue. I'm only about 100 miles from you, just in case you've exhausted everything local. You do need an experienced MS specialist to follow you. Your symptoms are classic!

ess

[jdhecaj]

Interesting what you wrote that if there is damage it will still be there and show? Not that a previous episode of ON will always show? If it doesn't show there is no damage? I know that damage can be on the back of the optic nerve so it will not show when the eye is examined. That I think is called Retrobulbar Neuritis.

I know that MRI's that are used now to show Retrobulbar Neuritis, but were not available when I had my first ON...and it was diagnosed and treated by an Opthamologist, so it did happen. The Opthamalogist diagnosed Optic Neurits instead of Retrobulbar Neuritis, must mean that it was on the visible part of my Optic Nerve or he would have diagnosed Retrobulbar Neuritis where it couldn't be seen.

The fact that no eye exam since has identified any difference in that eye even when told ON happened in that eye must mean it healed fully and the past ON is not visible on the Optic Nerve.

It's my strong eye too. I didn't need glasses until about 10 years ago & the ON was 20 years ago. And then I required safety glasses at work, not really glasses for seeing.

I don't think old incidences of optic neuritis can ALWAYS be detected on exam when a person no longer has symptoms & I'm curious if they are visible when symptoms are present. I'll ask, if it is visible when I get my eyes checked next time in a few more months. Certainly I have symptoms in one eye.

[essdipity]

No, what I said was that damage will remain, not that it can always be seen.

Here is part of what Quix wrote about a week ago:

There is a test called Optical Coherence Tomography, OCT - which is done on the otpic disc (through a dilated eye).  It was developed at Johns Hopkins in the last few years.  It is able to measure the thickness of the very outside edge of the optic disc where all the nerves are fanning out to cover the retina.  Via studies they determined that the thinning (atrophy) of the optic disc parallels the atrophy of the brain and/or spinal cord.  So they can monitor this parameter during a person's disease in place (sometimes) of an MRI.  It's much quicker and cheaper.

OCT then demonstrates that a person with MS has some measure of Optic Neuritis all along.  At least that is what I understood from my neurologist.  Because ON is what causes the thinning of the optic nerve and if they can use this test on all/most people with MS then that means that all/most people with MS have recurring demyelination of the optic nerve - ie . optic neuritis.  I don't think I ever had any visual symptoms, yet my OCT does show mild atrophy on the left and borderline atrophy on the right.  Weird, eh?
------------------

ess

[Eyesnlegs]

My ON was dx as Retrobulbar Neuritis too the first time around and the damage was seen on the optic nerve by anMRI exam.

In fact it was one of the first things my neuro realised as I had had ON 14 years before being reffered to him and was then suffering my second bout.

I have had opthamologists and my neurologist comment on a pale lens though and that it was indicative.

I would be interested if anyone else has had this as my eye issues are pretty major some days. I often wear an eye patch to try to conteract the effects and I wear sunglasses most of the time.

Pat
x

[ashleyPT]

I've never been diagnosed with ON, but I see a neuro-ophthalmologist soon.  My worst visual symptoms were in late January when I had an increased in blurred vision in the right eye, pain with any eye movement, and trouble seeing the color red.  I actually had no clue what the symptoms of ON even were, until I saw them this morning and it sounds suspect.  Since my symptoms are improving now, I didn't want it to be a waste that I was seeing the Neuro-opth in a week.  I had a VEP, but it was before I had any of those symptoms.

Thanks for all of your help and input.

[PastorDan]

When you say "pale lens", do you mean the iris?  I always thought that the lens is clear, except it becomes milky white gradually with the development of cataracts.  My assumptions and recollections on this topic might be way out in left field.  Oops, bad analogy to use when shouting across the pond!  Anyway, just asking.  Peace & blessings.

[jdhecaj]

You made a good point about what is a pale lens. It sent me to Wikipedia. It was interesting.

Optic neuritis is inflammation of the optic nerve, which causes loss of vision usually due to the swelling and destruction of the myelin sheath covering the optic nerve.

Major symptoms are sudden or gradual loss of vision (partial or complete). There may or may not be pain on movement of the affected eye. Patients may lose some of their color vision in the affected eye, with colours appearing subtly washed out compared to the other eye.

On medical examination the head of the optic nerve can easily be visualised by an ophthalmoscope. A pale disc is characteristic of optic neuropathy. Primary and secondary optic neuropathy may have different morphological presentation. The nerve head in optic neuritis may be swollen in some patients. In many cases, only one eye is affected and patients may not be aware of the loss of color vision until the doctor asks them to close or cover the healthy eye.

The optic disc or optic nerve head is the location where ganglion cell axons exit the eye to form the optic nerve. There are no light sensitive rods or cones to respond to a light stimulus at this point. This causes a break in the visual field called "the blind spot" or the "physiological blind spot". The optic nerve head in a normal human eye carries from 1 to 1.2 million neurons from the eye towards the brain.

The optic disc is placed 3 to 4 mm to the nasal side of the fovea. It is a vertical oval, with average dimensions of 1.76mm horizontally by 1.92mm vertically.[1] There is a central depression, of variable size, called the optic cup.

The eye is unique because of the transparency of its optical media. Almost all eye structures can be examined with appropriate optical equipment and lenses. Using a modern direct ophthalmoscope gives a view of the optic disc using the principle of reversibility of light. A slit lamp biomicroscopic examination along with an appropriate aspheric focusing lens (+66D, +78D or +90D) is required for a detailed stereoscopic view of the optic disc and structures inside the eye. Inspection of the optic disc by ophthalmoscopy or biomicroscopy can give an indication of the health of the optic nerve. In particular, the eye care physician notes the colour, cupping size (as a cup-to-disc ratio), sharpness of edge, swelling, hemorrhages, notching in the optic disc and any other unusual anomalies. It is useful for finding evidence corroborating the diagnosis of glaucoma and other optic neuropathies, optic neuritis, anterior ischemic optic neuropathy or papilledema (i.e. optic disc swelling produced by raised intracranial pressure), and optic disc drusen. Women in advanced stage of pregnancy with pre-eclampsia should be screened by an ophthalmoscopic examination of the optic disc for early evidence of rise in intracranial pressure.

[jdhecaj]

Optic Neuritis:

Symptoms

Major symptoms are sudden loss of vision (partial or complete), or sudden blurred or "foggy" vision, and pain on movement of the affected eye. Many patients with optic neuritis may lose some of their color vision in the affected eye, with colors appearing subtly washed out compared to the other eye. A study found that 92.2% of patients experienced pain, which actually preceded the visual loss in 39.5% of cases.[2]

On medical examination the head of the optic nerve can easily be visualised by an ophthalmoscope;****however FREQUENTLY there is no abnormal appearance of the nerve head(optic disc) in optic neuritis, though it may be swollen in some patients. In many cases, only one eye is affected and patients may not be aware of the loss of color vision until the doctor asks them to close or cover the healthy eye.

[jdhecaj]

It is like essdipity said, a Neuro Opt will have the OCT available and will be able to see the effects of your ON on your Optic Nerve. I was just excited to read that FREQUENTLY there is no abnormal appearance of the optic head(optic disc, lens). It's like I don't & never did have a pale lens, does that mean I didn't have ON and let some ophthalmologist treat me for it any way? & let a neurologist use the fact that I was treated for ON in the past to diagnose MS...along with the MRI and current symptoms. Was it all a fallacy that I had ON? It would seem like the whole house of cards would fall because I don't have a pale lens. I was just relieved to read in Wiki, that FREQUENTLY there is no abnormal appearance of the optic disc.

As relieved as I was, it may have concerned you that you had an appointment with a Neuro Opto and evidence of past ON might not show. It might not show on the lens, it FREQUENTLY doesn't, but it would show in OCT which a Neuro Opto will be able to do and will show your past ON. It's a good thing you have that appointment.

[Dizzybrunette721]

My neurologist said that generally the optic nerve will have an abnormal appearance, a paleness, that persists for quite some time after an episode of ON.

[Quixotic1]

A couple corrections are needed.

The area of the eye that shows optic neuritis is the optic "disc".  This is the place on the retina (the back of the eye) where the optic nerve comes out.  The lens is the clear, focusing part of the anterior eye behind the pupil.  The iris is the anterior colored area that we see as blue eyes or brown eyes.

Retrobulbar neuritis is actually Retrobulbar Optic Neuritis.  The words Optic Neuritis refer to any inflammation on the optic nerve from where it leaves the eye all the way back to the brain.  Retrobulbar refers to that part of the optic nerve that is farther back behind the eyeball.  All the literature states that after optic neuritis heals (no matter if it is retrobulbar or not) it should leave a person with an abnormal VEP forever.  However, there is a lot of variability in how the VEP is performed and interpreted.  So, some people with a history of ON will have a "normal" VEP in the future.

Whether the disc is pale from loss of fibers is relative.  If the damage is very slight, the examiner may not be able to percieve the faint paleness.  There has to be quite a bit of damage before it is visible - hence the hope that OCT will be useful.

In general, anywhere in the central nervous system, when an area of demyelination heals, the healing is NOT PERFECT, so the function of that nerve will always be a little slow.  That is why you don't have to be having symptoms for an Evoked Potential to be abnormally slowed.

Does this help clear up some of the questions?

If you google

optic disc

you will see a site that show pictures of the retina and shows the disc.

Quix

[Erin0313]

Quix,

  Thanks for the scoop on ON. I think I get it.

   One more question if you or anyone else knows. As you know I have had 2 episodes of ON already this year requiring 5 days each of IV Steroids. I now have the beginning of a cataract in my left eye.

One doctor says it's from the ON and the other says it's form steroids.

I see a neuro-opthamologist next month but am curios which is it and should I say no to the steroids because they are giving me a cataract?


Thanks,
Erin :)

[essdipity]

I'll be interested in comments on this. I've never heard of cataracts being caused by either ON or steroids, so if someone has good info, please let 'er rip.

You are very young for a cataract, but at the same time, cataracts are not entirely an old people's disease. Babies have been born with them, and they can occur at any age thereafter.

The good news is that cataract surgery (if needed---not all are that bad) has become incredibly easy on the patient. Almost no discomfort or down time. Very few complications. And the best news of all is that once the surgery is done, the cataract can't recur. So from that standpoint you are set for life.

If you need steroids, I say get them. And please let us know what the neuro-ophth says about this.

Hang in there.

ess

[PastorDan]

Ophthalmologist I saw last December -- after the faintly hazy patch appeared to the upper right, but before I began to experience eye pain -- said I had the very faintest hint of cataract in each eye, but that it was very faint, and might never be a problem.

jdhecaj, these words hit me square in the face: "Many patients with optic neuritis may lose some of their color vision in the affected eye, with colors appearing subtly washed out compared to the other eye."  I've used very similar terms in describing the odd patch in my field of view, but I think this is the first time that I've seen a reference talking about the color vision issue.

[PastorDan]

Oh, and I forget where I mentioned it, but I learned today that I'm to see a neuro-ophthalmologist mid-May.  Yes, I told them to call if they have a cancellation.  They put me on the list, but warned it's a long list already.

[jdhecaj]

Thanks for clearing up the definitions of lens & optic disk. I had looked at diagrams of the optic disk and thought that must be the lens that people speak of. But it is different. I didn't have as much success a googling optic lens. I just got glasses when I tried it..

[Erin0313]

ess,

   Hi! I'm hanging in there like you said. Thanks for the "good" news about cataract surgery. One less thing to be freaked out about. Now I won't worry about maybe having to have surgery in the future since you say it's not so bad and how great that it is a one time deal.


I will keep you posted on the neuro-ophth appt and what they have to say.

Pastor Dan is going in May also so we can compare notes :)

Hugs,
Erin :)

[PastorDan]

I just hope they didn't schedule that instead of the neuro-psychologist they told me I'd be seeing.  I don't mind seeing both.  Shucks, throw in a couple more, as far as I'm concerned.  Just get 'em done and figure this thing out.

BTW, I've never known a soul to have problems with cataract surgery.  One guy I worked with years ago had a bad Lasik surgery, but I think that's different.  Most who go through cataract removal are soon thankful, in my experience.

[Quixotic1]

Yes, steroids can cause cataracts.  In kids with Lupus and other diseases that get large amounts of steroids we can see cataracts after just a year or so.  It is a cummulative dose-related thing.  The more steroids you get through your life the more likely you are to get cataracts.

Quix

[Quixotic1]

I am not aware of any mechanism by which ON causes cataracts, but I am weak in ophthalmologiy.

Steroids, on the other hand, have a potent ability to cause cataracts.  That I know for sure.

Q

[Quixotic1]

I have the attention span of a gnat --- OH! Look a Squirrel!

I finally understood one of the first questions.  After ON heals if the optic disc was pale before, generally it will stay pale.  As for MRI lesions, those often clear up which again, tells us that the MRI doesn't show everything!

Here is a site that has a lot of stats and great pictures about ON and its lingering effects.  From Denmark I think.

http://www.jandoerffel.de/on.htm

[Eyesnlegs]

To Pastor Dan - So sorry I hadn't noticed the questions been very busy today.

To Quix - Thanks so much for clearing this up. My first ON was 20 years ago and was very dramatic - total blindness in 1 eye and it never really healed completely. I have since had it again in the same eye although I have also had a slight occurrence in the other eye. Only the eye with the original ON has a pale lens not the other eye.  

I have had ophthalmologists, opticians and the neuro comment on the pale lens, so Quix info has been very enlightening. My colour vision is only slightly affected but the double, blurred vision and strange eye stuff carries on.

The web site is excellent - useful discussion  guys.

Pat

[Quixotic1]

The stats are that from 64% to over 70% of all people with ON will have a NORMAL- appearing optic disc on exam.  Any doc that tells you that a normal physical eye exam means you don't have optic neuritis, doesn't know much about the disorder.  See?  I said that without dissing the stupid doctors.  

Quix

[hbananas]

Here's the flip side of the question:  Can someone have had ON long ago, but now have normal-looking optic disc and retina, and have normal VEP and OCT tests?  I've had my little scotoma for about 10 years, but everything looks fine to the pros.  I wrote the long-ago doctor to see if they could send me records, and the answer is yes--but I don't have them yet.

[Quixotic1]

This would be a god question for the extert.  The answer is probably yes, if the episode caused very little damage and those tests were normal at the time of the attack, but really the answer from me is:

I don't know.  :((

Quix

[PastorDan]

Quote from Quix, above: "See?  I said that without dissing the stupid doctors."

Reply: ROFLM*O! <~~ Rolling on floor laughing my asterisk off!  

Pat: No reason you should be sorry for not answering my question.  After all, I'm the one who saw a notice that yesterday was your birthday and neglected to wish you a happy one.  Just to compensate for that, I will pray that the rest of yours are happy!

[jed9999]

Just as one example---I went totally blind in 1973 (for about 6 wks or more as I recall.) My vision was totally retuned over time with Deltasone. For many years they have said I had a pale optic nerve when they examined me--BUT they no longer say that~ They say it looks very healthy now.

Another curiosity---Twice in the past 10-15 years I have awakened and gone blind momentarily in one eye when I opened my eye initially for maybe one to two seconds. (The room had some light.)I had a carotid artery scan which was quite clear. No reason was ever detected. Anyone else have this? I've had MS over 36 years---weird stuff keeps happening! Jane

[Eyesnlegs]

To PastorDan - and no apology from you necessary either the time lag often causes a pronlem and my wonderful family here sure made a new girl feel special yesterday.

To Jane - yes I have had this too, the mornings are the worst for vision stuff for me the momentary blindness has happened a few times but I wake up every morning with only partial sight in one eye. There are patches of grey in my sight and everything seems to shimmer. The ghosting I see on objects is apparently incomplete double vision and as of things move towards me quickly they split into 2 images. I have been told this is now due to weak eye muscles also causing a type of convergence disorder.  Driving is out of the question on a ad vision day.

I still get flashing lights (can't remember the medical term) for a few seconds in a dark room and when I move my head quickly. This surprises me as the website Quix gave above explains how this clears up eventually after an  of ON Does that mean that mine is still active?

In spite of all this my VEP was described as 'borderline' whatever that means.

Pat

[ncowleyc]

Oh my god, I am sooo glad I am not the only one who has this problem with their eyes. I tried to tell the neuro-optho about the trailers and she gave me a funny look. I think she thought I was taking acid, lol. I have woken up with one eye gone gray more than once. It lifts after a minute, but in the back of my mind is always, will this be the day I go blind? It's funny it quit when winter came but now it's back with a vengeance with spring on the way. God I dread summer, shudder.  

[Erin0313]

Quix - Thanks for the laugh - I needed that!!!!

All :
  I just received a copy of my recent VEP comment please

  Interpretation: This is an abnormal visual evoked potential. We could not identify the P100 on the left. There was a lot of technical difficulty as apparently the patient could not hold her eye open which is an unusual finding in optic neuritis from a clinical standpoint. The examiner needed to hold her left eye open. This may have induced a strong technical component. In acute optic neuritis, usually the P100 is present but markedly prolonged. Clinincal correlation is warranted.

Latency of P100  - 101 Right eye Not identified Left Eye

Ok so I have MAJOR cognitive issues so these reports are like gimmerish to me except positive vs. negative but what the heck?!

First I didn't like the word appararently. The examiner is the one who decided my eye wasn't open enough and she would just hold it with her finger. Are they saying that I was faking? How do you fake a twitching/lazy eye?

Or are they saying that my left eye basically wasn't working at all?

I will ask the neuro in May but for those of you that have had these maybe some opinions in the mean time.

Thanks,
  Erin :)

  

[Erin0313]

Bump

There is so much activity this was ready for page 3 and I am hoping for input


Thanks
Erin :)

[Nancy T]

Hi Erin--I can't answer your questions, but I remember that my optometrist used to keep telling me to open my eyes wider and was surprised when I couldn't--I absolutely couldn't. She even had to hold my eyes farther open (for some part of the exam).

And when I'd get a VNG (vestibular testing with goggles on your eyes), apparently I didn't do so well at keeping my eyes open either--I FELT like I was, I was really trying as hard as I could, but the audiologist kept saying over and over "Keep those eyes WIDE open!"

Nancy

[Erin0313]

  Nancy,

   Thanks for sharing. It's good to know that I'm not the only one that just couldn't do it! Also I thought having my eye held open was strange but I guess it is not uncommon after all.

  I have never had or heard of a VNG. I wonder if that test will be in my near future. I am seeing a neuro-opthomologist (sp?) in May. I have never seen one but am told if you have had ON it is very important. Maybe he/she will have lots of answers for me and actually explain in terms that I can understand, lol.

Thanks again - Take care

Erin :)