A 36-year-old woman comes to the emergency department with 2 days of mild right eye pain worsened by eye movement. She also describes a persistent black spot in the center of her vision. She has no recent respiratory infection, fever, or headache.
On examination, there is no eye redness or exudate. Funduscopic examination shows mild hyperemia of the right optic disk.
MRI of the head shows several scattered ovoid-shaped, periventricular white matter lesions.
Which of the following is the best initial treatment for this patient?

Question

A 36-year-old woman comes to the emergency department with 2 days of mild right eye pain worsened by eye movement.  She also describes a persistent black spot in the center of her vision.  She has no recent respiratory infection, fever, or headache.
On examination, there is no eye redness or exudate.  Funduscopic examination shows mild hyperemia of the right optic disk.
MRI of the head shows several scattered ovoid-shaped, periventricular white matter lesions.
Which of the following is the best initial treatment for this patient?

Quizplus · Accepted Answer

This patient's presentation is consistent with optic neuritis, an inflammatory demyelinating condition of the optic nerve leading to acute visual loss. Optic neuritis is likely immune mediated and typically presents with acute monocular vision loss over a period of hours to days, eye pain, central scotoma, and loss of color vision out of proportion to loss of visual acuity. Examination can show afferent pupillary defect, hyperemia/swelling of the optic disk, and blurring of disk margins with distended veins. Optic neuritis Optic neuritis is frequently associated with multiple sclerosis (MS). Approximately 15%-20% of MS patients initially present with optic neuritis, and nearly 50% develop it during the course of their illness. MRI of the brain and orbits with gadolinium can show optic nerve inflammation and characteristic findings of MS, including ovoid-shaped periventricular white matter lesions that are >3 mm. periventricular white matter lesions In general, oral and intravenous corticosteroids are considered equally efficacious for the treatment of acute MS attacks. However, intravenous methylprednisolone is preferred in patients with acute optic neuritis as oral therapy is associated with increased risk of recurrent optic neuritis (Choice D). (Choice A) Aspirin is given for atherosclerotic vascular disease, which is unlikely in this young patient. (Choice C) Intravitreal vascular endothelial growth factor is used for the treatment of retinal vein occlusions and macular degeneration. MRI would not show periventricular white matter lesions in these patients. (Choice E) Topical pilocarpine can lower intraocular pressure in acute angle-closure glaucoma. Patients typically develop the acute onset of decreased vision, halos around lights, headache, severe eye pain, and nausea/vomiting. Examination can show conjunctival erythema, corneal edema, and a mid-dilated pupil reacting poorly to light. MRI usually does not show abnormal findings, as seen in this patient. acute angle-closure glaucoma Educational objective: Optic neuritis typically presents with acute monocular vision loss over a period of hours to days, eye pain, central scotoma, and color vision loss out of proportion to loss of visual acuity. It is frequently associated with multiple sclerosis. Intravenous methylprednisolone is the preferred treatment as oral glucocorticoids are associated with increased risk of recurrent optic neuritis. __________ References: Multiple sclerosis: a primary care perspective. (http://www.ncbi.nlm.nih.gov/pubmed/25368924) Acute demyelinating optic neuritis. (http://www.ncbi.nlm.nih.gov/pubmed/12441840) Evolving management of optic neuritis and multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/15953446)

A 36-Year-Old Woman Comes to the Emergency Department with 2