Optic-nerve-sheath Meningioma Commonly Misdiagnosed as Optic Neuritis

By Reuters Staff

December 31, 2018

NEW YORK (Reuters Health) - A variety of errors contributes to the common initial misdiagnosis of optic-nerve-sheath meningioma (ONSM) as optic neuritis, researchers have found.

ONSM classically presents as the triad of progressive visual loss, optic atrophy and the presence of retinal-choroidal collaterals, but it is rare that all three findings occur simultaneously. Still, timely diagnosis and appropriate management are crucial for favorable visual outcomes, Dr. Valerie Biousse of Emory University School of Medicine, in Atlanta, and colleagues note in JAMA Neurology, online December 17.

They sought to identify factors contributing to the initial misdiagnosis or delayed diagnosis of ONSM in a review of data on 39 patients seen in their neuro-ophthalmology clinic.

Overall, 25 patients (71%) had delayed or missed diagnosis as a result of at least one error at some step of the diagnostic assessment process.

Clinician assessment failures were primarily responsible for the misdiagnosis in nine cases (36%); six patients had delayed or missed diagnoses because of a failure in eliciting or a misinterpretation of a physical examination finding (such as a fundus examination); five experienced failures in ordering or interpreting appropriate radiologic tests; and five had delayed or missed diagnosis resulting from poor history taking.

Just over half of the cases involve more than one diagnostic error, with about a third resulting from failures in clinician assessment.

Nearly half of the 25 patients (48%) received a misdiagnosis of optic neuritis at some step during their diagnostic process. Retinal macular disease was the second most common misdiagnosis.

Five patients in the misdiagnosed group underwent unnecessary lumbar puncture, 12 had unnecessary extensive laboratory tests and six have been treated with steroids. One patient had retinal laser treatment because of a misdiagnosis of retinal disease.

Among the 25 patients with misdiagnosis, 16 (64%) experienced a deterioration of vision, with 10 (40%) having very poor visual outcomes. In contrast, only three patients (10%) without diagnostic errors had a deterioration of vision, with the worst final visual acuity being 20/70 in the affected eye.

Patients with a misdiagnosis tended to be younger and to have a longer time from symptom onset to definitive diagnosis; they saw more clinicians and attended more office visits than patients who received the correct diagnosis of ONSM initially.

"Considering compressive optic neuropathies in the differential diagnosis of monocular painless progressive vision loss and accordingly ordering the appropriate diagnostic tests are important," the researchers conclude. "Recognizing an optic neuropathy, accurately performing funduscopy, and properly ordering and reviewing neuroimaging will improve the diagnostic process and help avoid unnecessary investigations and delayed treatment."

Dr. Biousse did not respond to a request for comments.

SOURCE: https://bit.ly/2SbU4nq

JAMA Neurol 2018.