Which clinical history findings are characteristic of optic neuritis in multiple sclerosis (MS)?

Updated: Feb 21, 2019
  • Author: Fiona Costello, MD, FRCP; Chief Editor: Hampton Roy, Sr, MD  more...
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Many of the cardinal clinical features of optic neuritis have been identified based on the Optic Neuritis Treatment Trial (ONTT). [12, 13] The ONTT revealed that most patients with typical optic neuritis are white (85%) and female (77%) with a mean age of approximately 32 years. [12, 13]

Among adults, sporadic optic neuritis cases are typically unilateral; however, bilateral simultaneous vision loss may be observed. Nonetheless, in this setting, other demyelinating optic neuropathies and potential optic neuritis mimics need to be considered, including neuromyelitis optica (NMO) and Leber hereditary optic neuropathy (LHON) (see Table 3).

From a clinical perspective, a comprehensive history is imperative for differentiating optic neuritis from its potential mimics. Patients with optic neuritis often report subacute-onset vision loss that worsens over hours to days. This mode of onset helps distinguish optic neuritis from anterior ischemic optic neuropathy (AION). [14] In contrast, AION is generally unaccompanied by pain, and symptoms are frequently noted upon morning awakening. Patients with compressive optic neuropathies may report sudden-onset awareness of vision loss. However, a detailed discussion often reveals that these individuals have experienced sudden-onset awareness of a longer-standing problem, rather than sudden-onset vision loss itself. [14]

Ninety-two percent of individuals with typical optic neuritis experience pain that is frequently provoked by eye movements, within the first two weeks of symptom onset. [10, 11, 12, 13, 14] Patients may also report intermittent flashes of light in the affected eye, known as photopsias or phosphenes. [15] Patients with optic neuritis may also describe worsening vision with increased body temperature, referred to as Uhthoff phenomenon. [11, 16]

Table 3. Differential Diagnoses of Optic Neuritis (Open Table in a new window)


Clinical Features

Investigations to Consider


Painless, altitudinal visual field defect is common, vision loss noted upon awakening, vascular risk factors, phosphodiesterase type 5 inhibitor use, nocturnal antihypertensive use, sleep apnea, physiological disc at risk, patients with NAION have optic disc edema acutely

Sleep study, 24-hour blood pressure monitoring, investigations for hypertension and diabetes

Compressive optic neuropathy (pituitary lesions, meningiomas, aneurysm)

Painless, progressive vision loss, color loss disproportionate to visual acuity deficit, nonglaucomatous optic disc cupping, temporal visual field cut, bilateral visual field involvement

Cranial and orbital MRI/MRA or CT/CTA

Infectious optic neuropathies (eg, tuberculosis, syphilis, Lyme disease, among others)

Associated uveitis, papillitis or retrobulbar optic neuropathy, macular star, infectious symptomatology

Serum/CSF culture/sensitivity; specific serological testing for syphilis, Lyme, Bartonella henselae, HIV, toxoplasmosis, viral hepatitis B and C; Epstein-Barr virus; histoplasmosis; tuberculin testing; chest imaging; serum sedimentation rate, C-reactive protein

Inflammatory/demyelinating optic neuropathies not associated with MS or an underlying systemic disorder: NMO, CRION, ADEM, anti-MOG–associated optic neuritis

Poor recovery, unilateral or bilateral optic neuritis, associated transverse myelitis, recurrent symptoms

Brain MRI, cervical spine MRI, anti-NMO antibody testing

Genetic optic neuropathies (LHON, autosomal-dominant optic neuropathy)

Bilateral vision loss, painless, poor recovery, family history

Genetics referral with specific mutation testing

Toxic/nutritional (tobacco-alcohol amblyopia and Cuban and Tanzanian epidemic optic neuropathies)

Bilateral optic nerve involvement, history of drug use (ethambutol, selenium, amiodarone), restricted nutritional intake, glue sniffing, methanol ingestion

Vitamin B-12 levels, toxic screen

Sarcoid optic neuropathy

Steroid responsive, poor recovery, systemic symptoms and signs

Chest imaging, serum ACE, Gallium scan, tissue diagnosis, bronchoalveolar lavage, soluble IL-2 receptor

Connective tissue/vasculitic optic neuropathy (lupus, Wegener granulomatosis, Sjögren syndrome, Behçet disease)

Steroid responsive, associated systemic symptoms and signs

Serum ESR, Sjögren specific antibodies, CRP, ANCA, ENA panel, ANA

Orbital inflammation/optic perineuritis

Orbital signs (proptosis)

MRI or CT orbital imaging, blood work including TSH ANCA, CRP, ESR, ACE

Uveitis/posterior scleritis

Severe pain, floaters, vitreous reaction

Fluorescein angiography, B-scan ultrasonography of orbits

Autoimmune optic neuropathy (Similar to CRION)

Steroid responsive

Skin biopsy for immunoglobulin deposition

Big blind spot syndromes

Blind spot on visual field testing, painless, photopsias, bilateral ocular involvement

Full-field/multifocal ERG, fluorescein angiography

Abbreviations: ACE = angiotensin converting enzyme; ADEM = acute disseminated encephalomyelitis; anti-DS DNA = anti-double-stranded DNA; anti-MOG = anti-myelin oligodendrocyte glycoprotein; ANA = anti-nuclear antigen; AON = autoimmune optic neuropathy; CRION = chronic relapsing inflammatory optic neuropathy; CSF = cerebrospinal fluid; ESR = erythrocyte sedimentation rate; FTA-ABS = fluorescent treponemal antibody absorption; HIV = human immunodeficiency virus; MRI = magnetic resonance imaging; NAION = nonarteritic anterior ischemic optic neuropathy; NMO-IgG = neuromyelitis optica immunoglobulin G; PCR = polymerase chain reaction; VDRL = Venereal Disease Research Laboratory

Table 3. Differential Diagnoses of Optic Neuritis (Modified From Table 2-1 in Costello F. Inflammatory optic neuropathies. Continuum (Minneap Minn). Aug 2014; 20 (4 Neuro-ophthalmology): 816-37.] [14]

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