Atypical Presentation of Optic Neuritis in Multiple Sclerosis : a - PDF document

Atypical Presentation of Optic Neuritis in Multiple Sclerosis : a Rare Case Abstract Introduction Optic neuritis is a term used to describe an inflammation of the optic nerve. The pathogenesis of optic neuritis is presumed to be demyelination, as occur in Multiple Sclerosis (MS). Optic neuritis present in about 50% of patients withh MS, customarily with typical demographic and clinical presentation. Purpose To report the occurence of atypical presentation of optic neuritis in a patient with MS. Case report A 19 year-old male first came to Cicendo Eye Hospital on April 2018 with chief complaint of blurred vision on the right eye. General examination revealed his Body Mass Index was 36.41, included in obese category. Ophtalmologic examination revealed visual acuity of light perception on the right eye, 1.0 on the left eye, and positive Relative Afferent Pupillary Defect (RAPD). Posterior segment examination of the right eye showed optic disc swelling with segmental pallor, peripapillary hemorrhage, macular star and retinal exudate on the right eye. Laboratory examination showed abnormal lipid profile and no active infection. The patient was diagnosed with right optic disc atrophy as a result of post neuroretinitis with obesity and dyslipidemia. Intravenous methylprednisolone was given as treatment . On June 2018, the patient came with chief complaint blurred vision on the other eye. Ophtalmologic examination revealed visual acuity of hand movement on the right eye, 0.5 on the left eye. Posterior segment examination on the right eye showed optic disc pallor, and on the left eye showed optic disc swelling with segmental pallor, and peripapillary hemorrhage. The patient was diagnosed with pseudo-foster kennedy syndrome as a result of recurrent optic neuritis or ischemic optic neuropathy, with dyslipidemia, and obesity. The patient was given oral methylprednisolone with gradual tappered dose every week. Visual acuity of the left eye was found to be improved 2 weeks after treatment, as measured 1.0 f2 with snellen chart. On follow up examination, ophtalmologic examination revealed visual acuity of hand movement on the right eye, 1.0 f2 on the left eye. Posterior segment examination on the right eye showed optic disc pallor, and on the left eye showed optic disc swelling and peripapillary hemorrhage. MRI result were consistent with McDonald 2010 criteria for MS. The patient was diagnosed with bilateral optic disc atrophy due to optic neuritis caused by MS. The patient was consulted with neurologist and received azathioprine oral as MS management. Conclusion Clinical presentation of optic neuritis caused by MS usually occur in a typical manner. Although rare, with thorough clinical examination along with careful differentials and aid from neuroimaging modality, atypical presentation of optic neuritis could also be found in patients with MS. Keywords Optic Neuritis, Multiple Sclerosis

2 I. Introduction Optic neuritis is a term given to inflammation of the optic nerve. The pathogenesis of optic neuritis presumed to be destruction of myelin sheath, also known as demyelination. Optic neuritis usually occur in primary demyelination process, whether as an isolated process or in patients with Multiple Sclerosis (MS). Optic neuritis usually occur in about 50% of patients with MS, and is the presenting manifestation in about 20%. 1,2 This case report will further discuss the occurence of atypical presentation of optic neuritis in a patient with multiple sclerosis. II. Case Report A 19 year-old man first came to Cicendo Eye hospital on 17 th April 2018 with a chief complaint of blurred vision on the right eye for 2 weeks. The complaint got worse for the last 2 days. He also felt pain around the right eye especially on eye movement, and headache. There were no nausea and vommiting. He did not have any history of previous similar symptoms. He denied any history of head injury, recurrent ocular redness, double vision, fever, flu like symptoms, vaccination, alcohol consumption, hypertension, diabetes mellitus, limb weakness, and problem with balance. Figure 2.1 Cardinal eye position

3 General examination revealed body height 169 cm, body weight 104 kg, with Body Mass Index (BMI) 36.41, which belong in obese category. Ophtalmology examination showed visual acuity was light perception on the right eye, and 1.0 on the left eye. Eye position was orthotropia, no ocular movement deficit or pain. Intraocular pressure were 17 mmHg on the right eye and 15 mmHg on the left eye. Anterior segment examination revealed pupillary light reflex were ↓/+ on the right eye with relative afferent pupillary defect (RAPD) grade IV and +/↓ on the left eye. Other anterior segment examination were within normal limit. Posterior segment examination revealed optic disc swelling with segmental pallor, peripapillary hemorrhage, macular star and retinal exudate on the right eye. Left eye were within normal limit. Figure 2.2 Fundus Photograph on April 2018 . Color and contrast sensitivity were difficult to examine for the right eye and revealed normal for for left eye. Visual field were difficult to asses for the right eye, and the left eye were within normal limit, as demonstrated by examination using humphrey visual field perimetry.

4 Figure 2.3 Humphrey visual field result of the left eye on April 2018 The patient underwent blood extraction for laboratory examination, that revealed reactive IgG toxoplasma 314.6 IU/mL, reactive IgG Rubella 301.3 IU/mL, reactive IgG CMV 84.42 U/mL, but none of the IgM were reactive. Lipid profile revealed high total colesterol 227 mg/dL, high LDL cholesteerol 165 mg/dL,low HDL cholesterol 38 mg/dL, and high triglyceride 244 mg/dL. Others were within normal limit. The patient was advised to underwent brain Magnetic Resonance Imaging (MRI) examination with contrast. The patient was diagnosed with early right optic disc atrophy as a result of post neuroretinitis or compressive optic neuropathy and ischemic optic neuropathy as a differential diagnosis, with obesity and dyslipidemia. The patient was treated with intravenous methylprednisolone 4 x 250 mg for 3 days, intravenous ranitidine 2 x 50mg, intravenous mecobalamin 1 x 500 mcg, and oral Ca hydrogen phosphate 500 mg, vitamin D3 (cholecalciferol) 133 IU 3 x 1 tablet. The patient was consulted to nutrition specialist for his obesity, and to internal medicine specialist for his dyslipidemia. On the third day, visual acuity on the right eye, anterior segment and posterior segment examination still showed the same result. The treatment then continued with oral methylprednisolone 1mg/kg body weight, that was tapppered weekly. On 26th June 2018, the patient came with chief complaint of blurred vision on the left eye. Ophtalmology examination revealed visual acuity was hand movement

5 on the right eye, and 0.5 on the left eye. Eye position was orthotropia, no ocular movement deficit or pain. Intraocular pressure were 17 mmHg on the right eye and 19 mmHg on the left eye. Anterior segment examination revealed pupillary light reflex were ↓↓ / ↓ on the right e ye and ↓ / ↓↓ on the left eye. Other anterior segment examination were within normal limit. Posterior segment examination revealed optic disc pallor on the right eye, and optic disc swelling with peripapillary hemorrhage on the left eye. Humphrey visual field perimetry was performed which revealed severe visual field defect with constriction of visual field. Figure 2.4 Humphrey visual field result of the left eye on June 2018 The patient was diagnosed with pseudo-foster kennedy syndrome as a result of recurrent optic neuritis or ischemic optic neuropathy, dyslipidemia, and obesity. Foster kennedy syndrome from space occupying lesion considered as a differential diagnosis The patient was treated with oral methylprednisolone 1mg/kg body weight, oral ranitidine 2 x 150 mg tablet, oral mecobalamin 1 x 500 mcg tablet, oral citicholine 1 x 1000 mg tablet, Ca hydrogen phosphate 500 mg, vitamin D3 (cholecalciferol) 133 IU 3 x 1 tablet. The methylpredisolone dose was adjusted with tappered dose every week, along with follow up examination. The visual acuity of the lef eye was found to be improved by two weeks follow up, with visual acuity 1.0f2.

6 One month later, the patient came for follow up with subjective feeling of improved vision on the left eye. Ophtalmology examination revealed visual acuity was hand movement on the right eye, and 1.0 f2 on the left eye. Eye position was orthotropia, no ocular movement deficit or pain. Intraocular pressure were 19 mmHg on the right eye and 16 mmHg on the left eye. Anterior segment examination revealed pupillary light reflex were ↓↓ / ↓ on the right eye and ↓ / ↓↓ on the left eye. Other anterior segment examination were within normal limit. Posterior segment examination revealed optic disc pallor on the right eye, and optic disc swelling with peripapillary hemorrhage and segmental pallor on the left eye. Color and contrast sensitivity were difficult to examine for the right eye and revealed normal for for left eye. Figure 2.5 Fundus Photograph, Humphrey Visual Field and OCT results