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Optic Neuritis question
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Optic Neuritis question

Last year I had a feeling of pressure behind my right eye.  Sometimes it was so severe there was pain and it felt like my eye was being pushed outwards.  My eyesight was very blurry in that eye. The symptoms lasted for several weeks.  I was seen by an Opthamologist, but after he looked into the back of my eye said he didn't see anything.  He said my vision was weak in that eye and suggested eyeglasses.

The symptoms went away after several weeks. I decided not to get glasses because I felt that was not the problem.  Whenever I have severe fatigue and depression my vision becomes severly blurry.  Does this sound like I may have had Optic Neuritis?
Thanks
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233622_tn?1279338505
Do you have a diagnosis?  Do you have other MS symptoms?
If not, you do need to get glasses and start there.  When I first had Optic Neuritis my eye doctor saw nothing in my eye that suggested ON.

He told me my eye problem was due to aging.  I already had glasses at that point. He told me to go home and wait to see what happened.  

I waited about 7 days and just knew something was not right so I went back to my eye doctor and he sent me to a Neuro opthamologist.  That eye doctor sent me in for an MRI because he couldn't even see the ON.

The MRI showed ON.

So, my point with saying all of this is Jump The Hoops.  If the doctor feels you need glasses, you need to get them.  

If your vision is still a problem go back to the eye doctor and ask him to send you to a neuro op.  

LA dx'd feb 2008


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The biggest joke in ophthalmology is: "Patient walk in and says I don't see anything from my left eye.  Dr looks in left eye and says I don't see anything either.  Must be Optic Neuritis."

If you have retrobulbar ON, the Ophthalmologist  should see indictions in the optic disk.  If it is back in the depths of the cranial nerve, the only way to detect it is a VEP or an MRI of the optic nerves (and the MRI is a big maybe.)  There is a lot of optic nerve that can be effected and most of it is inside your brain.

In my case, my exam was normal, but my VEP had decreased conduction velocity and amplitude with a well maintained waveform consistent with Optic Neuritis.

Bob

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Everyone on the forum remember that 64% of people with Optic Neuritis have a normal eye exam.  However, it seems few of the Ophthalmologists seem to know this.  We have even heard Neuro-Ophtho's state that a normal fundoscopic exam means no optic neuritis.

Bob - you got it slightly backwards or it was a misprint.  If the ON is bulbar, that is involving the part of the optic nerve that has already reached the eye, there is usually (but not always) some sign on exam.  In Retrobulbar Optic Neuritis the lesion is back behind the eye on the optic nerve, and typically NO change in the optic disc will be seen in the acute inflammation.

He is right.  If the symptoms suggest optic neuritis, and the exam is normal the next step would involve Visual Evoked Potentials (VEP), visual fields testing, color saturation testing, and/or an MRI which focuses down on the optic nerve.  Remember that a common symptom of optic neuritis is loss of color vividness in that eye.  Colors may seem washed out.

Eventually, if the damage to the optic nerve is severe enough, the optic nerve will atrophy and this can usually be seen on exam or with OCT.

Quix

In my case, I never had symptoms of ON, but on testing with OCT (Optical Coherence Tomography) I have measurable atrophy of the optic nerve on the left and borderline on the right.  Both of these are too slight to be seen on exam, however it is proof that I have had some optic neuritis in the past - apparently without symptoms.

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1225331_tn?1333369369
Do you usually need to ask for an VEP test or should the neurologist or opthamologist offer it to you? I've never had one.  

They didn't see my ON on my brain MRI. But since it takes so long to get into the neuro here (4-7 months), my brain MRI wasn't until 4 months after my ON presented.  

Lydia, the symptoms that you are having sound very strongly like ON to me.  Like LA, I was also wondering if you had any other MS type symptoms.

When I switched to a new neuro, he saw the moderate/severe APD (afferent pupillary defect) in both of my eyes and the pale optic discs. Plus, a visual fields test showed a handful of central scotomas in both of my eyes.

Good Luck,
Kelly
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147426_tn?1317269232
In Kelly's post, the key phrase was "When I switched to a new neuro..."

Yes, Lydia, those symptoms are characteristic of optic neuritis.  Does your eyesight also become bad when you get overheated?

Quix
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The big issue with ON it that the typical Ophthalmologist can only se retrobulbar inflammation. A Neurologist or Neuro-Ophthalmologist will typically order a VEP if there is a suspicion of ON.  When I had ON (Neuro Attack #1) the Neuro-Ophthalmologist ordered the MRI and VEP at the same time.  He also did a pretty complete Neurologic Exam so he could start a diagnostic timeline.

Even though a regular Ophthalmologist can order the VEP they lack the neurodiagnostic training to evaluate it.

Bob
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1453990_tn?1329235026
Yes I meant disk changes in bulbar.  My brain and finger don't alway connect to well.  I get the joy of going back and rereading posts that should have had better editing.  I had retrobulbar ON.  

One of the key things Quix said was an MRI focusing on the optic nerves.  That is not the same MRI of the Brain done with the MS protocol.  There are special sequences called Long Echo Time Short Tau Inversion Recovery that are typically used for imaging the optic nerves.  

This is a study I would not want done in an imaging center.  If it was me, I'd head to a teaching hospital with a 3 Tesla magnet and a large neurosurgical/neuro-oncology program.  They do a fair share of this type of imaging  
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Avatar_f_tn
As far as "needing glasses" . . . I had a similar incident, but I did get the glasses.  When they came in two weeks later, I couldn't see a thing with them . . . my vision had improved by that point.  Fortunately, I am able to rely on over the counter reading glasses.
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My Neurp-Ophthalmologist says wait 6-9 months after ON before having a new refraction done.   In most people, the vision will improve of that period of time as the nerve remyelinates and repairs itself.  Also, glasses will only correct vision issues with the eye itself.  If you have visual field defect or monocular double vision due to nerve damage, glasses will not correct this.

Bob
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Avatar_m_tn
Interesting discussion. I've been waiting to have my eyes checked because of the blurring that's been coming and going for the last several years. It started with bad headaches, and now is whenever my fever is up or when I get overheated like during and after a shower. I kept wondering if it would interfere with a prescription for eyeglasses.

The ophthalamologist who looked at them last week didn't see anything, but ordered a visual field test. What will a visual field test tell you that a VEP won't? She's not a neuro-optho, so probably doesn't have that equipment at her disposal.

Would it be redundant to follow up with a neuro-optho? I have one of those scheduled in a couple of weeks just in case for a back up.

Leave no stone unturned . . .
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Avatar_f_tn
I have what's called, Ischemic optic neuropathy.. I was diagnosed with that in 2007.  My opthalmologist told me that with this condition, #1 I could go blind and  #2 it will never get better. I have read about it as much as I possibly can, and I have noticed that most of the people that get diagnosed with this are older than 50, I was dx when I was 36. My thyroid eye disease was the culprit for this according to my doc..

.... 3 months later, I had a worsening of my eye symptoms,, really blurry, colors faded even more and of course pain. I had gone to see my opthalmologist. He did testing and my vision had gotten worse... fast forward to 7 months later, my vision got alittle better, not 100% but slightly better.

MY QUESTION IS.... If I have ischemic optic neuropathy and according to my doctor it will never get better, than how come when it got worse during that time it didn't stay ???? I have read from my internet researching on my visiual symptoms the difference between optic neuritis and optic neuropathy are basically the age that you are dx because everything else is the same.
unless I am wrong.
If anyone has info or input on this I would greatly appreciate it

Lydia:
I am soo sorry that I asked my question on your post, but as soon as I saw the optic neuritis post and read what you had been experiencing, I had gone through the same thing but mine was from different reasons, or so they thought,, i am so confused with all of this, but because we are so determined to get our answers ourselves, we will have more knowledge to bring with us to the next appts.

good luck to you, pamela
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1453990_tn?1329235026
Just because you have ischemic optic neuropathy doesn't mean that you didn't get hit with a case of Optic Neuritis.  While the ischemic optic neuropathy  may not improve, a bout of Optic Neuritis most likely would improve.
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What Bob said.
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751951_tn?1299202836
One question to which I've seen assorted answers: Does a NEGATIVE VEP rule out ON?
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1453990_tn?1329235026
I would say no.  A positive VEP shows an alteration in the conduction of the optic nerve.    I would suspect that there are other inflammatory processes that could effect the optic nerve and cause a "neuritis" (an inflammation of the nerve) that is not associated with demyelination or changes in conduction.  I'm not sure that some of the other inflammatory processes would cause the decrease in nerve conduction velocity while maintaining the waveform that are seen in ON caused by demyelination. So a non-demyelinating ON could still inflame the nerve without demyelination and, I think, you could have a normal VEP.  

Again, Quix may have insight on this that I do not.

Bob
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Avatar_f_tn
I've never gotten clarity on this either, Dan. From what I've learned, there are no absolutes with anything about MS, except the need for lesions, whether seen or unseen.

It would be quite rare to have a normal VEP yet to have had definite ON, but maybe some locations along the nerve would not produced delayed latency (?) I'm equally interested in the reverse situation---where VEP is abnormal but ON has not been diagnosed. I know that is quite possible in MS, and lots of people are in this category, including me. I have had no eye symptoms at all. There are a few conditions that can cause abnormal VEP other than MS, but these are quite rare and probably readily detectable by an ophtho.

Here are a couple of links that I find interesting. You've probably long since read them, but still....

http://www.virtualmedicalcentre.com/healthinvestigations.asp?sid=52#VEP_Detection

http://www.mult-sclerosis.org/VisuallyEvokedResponse.html

ess
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1257156_tn?1269461469
This is absolutely fascinating. I had a few symptoms of ON when I was having my worst constellation of symptoms (pressure feeling, pain, etc.). I was referred to a neuro-opthalmologist who examined me and said there was nothing wrong. Then he wanted to do an ERG test just to be sure. Which we did and it was normal. Somewhere in there I also did a visual vields test. All were fine. The one time I actually met with the neuro-opthalwhatever he totally made me feel crazy. He looked at my eyes and said, no everything's normal. When I described what was happening he got this look on his face that was a mix of skepticism and "aw, poor crazy person." Nowhere did he mention that it sometimes fails to show up. ARGH! I have been filing this under evidence that nothing is wrong with me, but I guess not.
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Avatar_f_tn
I often thought that, but I never wanted to show doubt in my doctors..  I am going to bring this up to my optic nerve specialist when I see him again, ( He is awesome) And he listens!!!!!!!!!
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1453990_tn?1329235026
NOTICE:  Techie stuff follows

ERG (electroretinography) only diagnosis diseases of the retina.  VEP looks at the wiring from the retina to the visual cortex in the posterior of the cerebrum above the cerebellum.  The expectation is that there should be a characteristic positive deflection 100-115 milliseconds (mS) after the visual stimulus for patients under 60.  If it is greater than 115 mS that is a "decreased conduction velocity."  That slowdown can happen anywhere from the beginning of the optic never of the eye under test to the optic cortex.  

There has been some discussion of the use of OCT in the diagnosis of Optic Neuritis.  My understanding of the technology is that it is closely related to LIDAR (LIght Direction And Ranging) or a "Light" based "Ultrasound."  Last I knew, the diagnostic depth of OCT was limited to about 2 mm.  My understanding is that OCT's high resolution makes it a superb tool for retinal imaging.  Unless things have changed, OCT is not really capable of diagnosing demyelination or ischemic changes of the retrobulbar optic nerve.

Anterior Ischemic Optic Neuropathy can be diagnosed with an OCT.  Again, the differential diagnosis of retrobulbar ION vs. ON is pretty difficult.  ION is the result of decreased blood flow and oxygenation to the retina or the optic nerve.  ON is a decrease in conduction velocity due to demyelination. Atilla et al found that VEP amplitude decrease was more significant in ischemic optic neuropathy, while optic neuritis showed more significant latency prolongation.

So ION has less amplitude (N75 to P100) with near normal latency (P100.)  ON has near normal amplitude (N75 to P100) but increased latency (peak > P115.)  I asked my neuro-ophthalmologist how he made the differential determination, and he replied ON patients typically regain some of their vision and improve over time. He said that in his practice ION is typically related to post surgical complications and he has not seen much improvement in these patients.

Bob
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Okay, techie,  would you look up the sensitivity and specificity of the VEP with regard to the diagnosis of ON and report back??

I have read varying opinions on this topic.

The OCT is not (yet) useful for diagnosing MS.  It is currently only used clinically for following the status of CNS atrophy.  As goes your eye, so goes your brain.

Quix
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Here are a couple of studies that jumped out.

Doc Ophthalmol. 2004 Jul;109(1):87-100.
Normative ranges and specificity of the multifocal VEP.
Fortune B, Zhang X, Hood DC, Demirel S, Johnson CA.

Discoveries in Sight, Devers Eye Institute, Legacy Health System, Portland, OR 97232, USA. ***@****
Abstract
PURPOSE: To describe a normative database for the multifocal VEP (mfVEP) and to evaluate specificity for a range of cluster criteria.

METHODS: One hundred persons (62 females and 38 males) with normal visual fields and ranging in age from 21.6 to 92.4 years participated in this study. Self-reported race in 80 of these 100 persons was 'White or Caucasian,' eight were 'Black or African-American,' eight were 'Asian,' and four were 'Hispanic or Latino.' Pattern-reversal mfVEPs were obtained using a dartboard stimulus pattern in VERIS and two 8-min runs per eye were averaged. A bootstrap technique was used to estimate the normal range of mfVEP response signal-to-noise ratio (SNR) and inter-ocular amplitude ratio at each location. Specificity (1 - false alarm rate) was evaluated for a range of cluster criteria, whereby the number and probability level of the points defining a cluster were varied.

RESULTS: There was no overall effect of age on SNR (r2 = 0.16, p = 0.22) nor was the interaction between age and location significant (F = 0.83, p = 0.82, ANOVA). The location with the largest age effect had an r2 of only 0.13. There was a small but significant effect of sex (t = 2.1, p = 0.04) such that SNR was slightly (11%) larger in females than males, but there was no significant interaction between sex and age (t = 0.82, p = 0.41). There was a slight trend toward higher SNR in the Asian group and lower SNR in the African-American group, but the overall effect of race was not significant (F = 1.99, p = 0.12). Specificity depended on the number and probability level of the points defining a cluster. Specificity did not vary by age group in a simple monotonic manner. False positive rates were slightly higher in females than males, and slightly higher in the African-American group as compared with the Asian group.

CONCLUSIONS: Excellent specificity can be achieved for the mfVEP by using particular cluster criteria for monocular and inter-ocular tests. The effects of age, sex, and race were all very small and only the effect of sex was statistically significant. This normative database can be used for analyses of mfVEP results from individual patients with little risk that demographic factors such as age and sex will confound diagnostic accuracy.

http://www.ncbi.nlm.nih.gov/pubmed/15675203
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Neurology. 2009 Jul 7;73(1):46-52.
Optical coherence tomography is less sensitive than visual evoked potentials in optic neuritis.
Naismith RT, Tutlam NT, Xu J, Shepherd JB, Klawiter EC, Song SK, Cross AH.

Department of Neurology, Washington University, St Louis, MO 63110, USA. ***@****

RESULTS: Ninety-six clinically affected optic nerves were studied. The sensitivity of OCT RNFL (Retinal Nerve Fiber Layer) after ON was 60%, decreasing further with mild onset and good recovery. VEP sensitivity was superior at 81% (p = 0.002). Subclinical ON in the unaffected eye was present in 32%. VEP identified 75% of all subclinically affected eyes, and OCT identified <20%. RNFL thickness demonstrated linear correlations with VA (r = 0.65) and CS (r = 0.72) but was unable to distinguish visual categories <20/50. RNFL was thinner with severe onset and disease recurrence but was unaffected by IV glucocorticoids. OCT measurements were not related to overall disability, ethnicity, sex, or age at onset. The greatest predictor for RNFL in the unaffected eye was the RNFL in the fellow affected eye.

CONCLUSIONS: Visual evoked potentials (VEP) remains the preferred test for detecting clinical and subclinical optic neuritis. Optical coherence tomography (OCT) measures were unrelated to disability and demographic features predicting a worse prognosis in multiple sclerosis. OCT may provide complementary information to VEP in select cases, and remains a valuable research tool for studying optic nerve disease in populations.

http://www.ncbi.nlm.nih.gov/pubmed/19564583

.
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Avatar_f_tn
After reading your post, I am hoping I get this right. I understand that ischemic optic neuropathy can be caused by the eye surgery.  The Docs. noticed the change while doing my follow up eye exam. He saw a speck or something and immediately sent me to the optic nerve specialist. This is when I had all sorts of eye exams and photos taken of the optic nerve and the disc cup ( I forgot what its called so dont mind my confusion) and it was very pale. i saw the picture and it was very dulled.
I was told not to lift anything over 40 lbs because of the risk of blindness in my right eye. I have been very nervous and careful since then. I am still told not to lift, push, pull bend, or do anything strenuous for the risk of visual loss.

anyway... when I had that second round of visual disturbance, i was extremely nervous.  It happened 4 months after my dx. of ischemic optic neuropathy. my vision was very blurry in the same eye. I could not see anything very well. I had gone to see my opthalmologist and he did my vision test and it def. had gotten worse. Once again I was sent to the optic nerve doc. I thought for sure my vision was deteriorating and eventually i was going to go blind in my right eye.

Then..... 7 months later, it got better.. this is when I started to think that maybe it was "something else" causing my vision to change. I truly believe that my changes in my eye was from "something else" because of it getting better.

Thanks Bob, I think its very possible that I was hit with a case of ON but because of my eye disease, everything else is masked and docs. are possibly overlooking this.

You guys are the best and i feel like I get great explanations that I so deserve!! Pamela
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So I'm thinking if they did a VEP, the ION would cause decreased amplitude (low signal) but if the peak occurred at time = 115 mS or more, there would be evidence to support ON with decreased conduction velocity.  

Bob
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Avatar_f_tn
I wish I knew the amplitude or peak , should I suggest this to my optic nerve specialist to check my tests and all of these numbers for evidence that could support ON.

I feel clueless with all of my tests because I have never asked for any of my reports, I just go with what they relay to me.

I know my doc. will be more than happy to share my info. I am very lucky to have a great eye specialist, they actually have a heart for me and always seem happy to see me, its a great feeling.

Bob, thanks so much for taking the time to share this with me, I will be making my appt. soon to see him and when I do, I will let you know what my reports say.


Hugs, Pamela :)
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