Scientific article

Neuritis infectious optics.

Report of a pediatric case
Ferrero Rosanas a. - OC No. 8951 - Cavero L. Roig - ophthalmologist - Sierra Lorente - OC No. 17113

Optic neuritis is an inflammation of the optic nerve can cause a sudden loss of vision in the affected eye. This inflammation can be
the result of an infection, poisoning or may be caused by hereditary diseases. With the following article we make a review of the
etiology and symptoms that accompany infectious optic neuritis. We present a pediatric case deepen the visual examination should
be performed and additional tests that allow us to establish an appropriate differential diagnosis.

KEYWORDS

Optic neuritis, papilledema, defec- to relative

afferent pupillary (RAPD), scotoma
centrocecal.

INTRODUCTION

The term optical neuritis 1 It makes reference

to inflammatory conditions or demyelinating
optic nerve (NO). When it affects traocular
in- portion is called papillitis and is
characterized by inflammation of co optical
arranged. Instead, retrobulbar neuritis talk
about if the rear portion of NO which is
affected da, so that the fundus is in principle Figure 1. Neuritis optical infectious: lifting and blurring the edges of the papilla is observed. Absence of

standard. bleeding and signs of neuroretinitis.

(AV), impaired function pu- pillar and color CLINICAL CASE

vision. Cia apparent perimetric examination
The parainfectious optic neuritis 2 for the presence of centrocecal scotoma. Came to our office an 8-year decrease in AV
It is consecutive to a microorganism Cerebrospinal fluid (CSF) of these patients refers OD 10 days of evolution. The patient
infection. The most frequent cause is that of revealed elevated protein with pleocytosis has no medical history or had fever or
viral origin 3 ( parotiditis, chicken pox, etc.) and and neuroimaging studies are normal evils. malaise in the ultra- scams days. No
more rarely bacterial or otherwise. It occurs ophthalmological history or use graduation.
between 1 and 3 weeks un- since the To date visual behavior was normal and
infectious episode and generally affects asymptomatic MOS- lock. In the emergency
children. It may be unilateral, but almost department practice cranial and orbital
always it is a bilateral acute neuropathy da 4 papilla magnetic resonance imaging (MRI) and
elevation. The prognosis of infec- postin- neuritis in general analysis. All tests are normal.
terms of visual recovery is excellent,
although HA- bitual is to persist with papillary
pallor subtle defects in visual function.
It is characterized by reduced visual acuity

3. 4 September 440 Gazette Optics

It is oriented such as optic neuritis and
derived ophthalmology unit for diagnosis and
treatment.

In the first ophthalmologic review ca, the

uncorrected visual acuity (UCVA) of light
perception OD is 10 cm that does not
improve with pinhole. AVSC of OI is unity.
Retinoscopy gives: OD: +3.00 / OI: +2.00. In
exploring the pupillary function we detect one
DPAR OD. Color vision (11 sheets
pseudoiso- chromatic Ishihara) pue- not
assess the OD due to its low and the AV IO is
normal. When performing retinoscopy under
cyclo- plegia the value obtained is OD:

+ 5.50 / OI: 0.50 + 4.00 10º. Extrinsic ocular

motility is Normal and the patient complained
of pain on ocular motility. In the substantive
examination initial lifting eye and blurring of
the edges of the papilla in OD seen. No
bleeding or signs of neuroretinitis are evident
( Fig. 1).

Serology is requested 5 for toxo- plasma

gondii, Toxocara canis, bar- Tonella
henselae, borrelia bugdor- feri, EBV
(Epstein-Barr virus), VDRL (syphilis) and
FTA-ABS (treponemal antibody absorption
fluo- phosphors excited), being all normal
results. Determining ACE (angiotensin
converting enzyme) and PPD (purified protein
derivative) re- sultaron negative. Treat- ment
with corticosteroids (1 mg x kg weight) with
proton pump inhibitors orally pattern.

Figure 2. perimetry, at the initial stage of optic neuritis, reveals an altitudinal scotoma affecting mainly the lower hemifield and
macular area.

At 2 days UCVA OD allows you to count
fingers at 80 cm (no improvement with
pinhole). AVSC of OI is unity. DPAR
continues manifesting a mild response direct
reflection in the OD. Perimetry OD ( Fig.
2) reveals an altitudinal scotoma
predominantly in the lower and central
involvement hemifield. Perimetry of OI is
normal.
At 15 days of evolution concerns the pa- cient maintained with progressive resolution lower
improvement. UCVA OD is 0.2 (no
improvement tenopeico is-) and UCVA OI is
unit. Assessment of color vision OD reveals a progressive decrease in the dose of systemic
teranomalía deu- and the OI remains normal. corticosteroids.
The biomicros- cópica exploration and
intraocular pressure are normal in both eyes. At 25 days, the OD is UCVA
The evolution is progressive ophthalmoscopic 0.8 (no improvement with pinhole) and the OI
tion pro sively decreasing elevation and is 1. Opthalmoscopy found that papillary
fuzziness of the papillary edges. And fuzziness level of the nasal edge pallor tem-
evidenced the temporal edge of the papilla ( Fig.porary industry persists. Perimetry has
normalized OD ( Fig. 5). From this moment the
treat- ment is suspended corticosteroid.
3). In perimetry of the central scotoma OD it is
scotoma ( Fig. 4). Fa- vorable before the onset
of symptoms begins At 45 days UCVA is 1in AO.
Retinoscópicamente encon-

Gazette Optics September 440 35


Figure 3. Improved fundus after 15 days of development, and where the temporal edge of the papilla is evident.
OD sections: +2.25 / OI: +2.00. Subjective consensual if we stimulate the other eye,
examination gives OD: +1.00 / OI: +1.00. without anisocoria on. The contralateral eye
Ishihara test confirms that color vision is instead presents direct and consensual reflex.
normal in AO and the exploration of This is known as the vo relative afferent
Funduscopic see that resolved the rise and pupillary defect (RAPD) or Marcus-Gunn
dad borrosi- papilla, while certain pallor pupil, and indicates the optical path pathology
persists temporary dominance ( Fig. 6). pre geniculate. If there is no response to light
but remains the consensual pupil speak
amauróti- ca. The RAPD is usually
proportional to the severity of the involvement
of NO 7.
DISCUSSION When the involvement is bilateral and if-
metric, there being no significant differences,
Optometric examination 6 and logic we can not talk about DPAR, but we observe
ophthalmological will prove of great a slow, lazy pupi- lar response.
importance, not only as co method
diagnoses optic neuritis, but also to assess
its evolution through treatment efficacy. Four. color vision . Most axons carry no
informa- tion of the macular area and in it the
most abundant photoreceptors are cones.
Among the optometric examinations that we The duration of the inflammatory process,
perform, we highlight the following: color vision is altered with a clear eye
discromatopsia affection, which in some
cases reaches not disappear completely.
1. Measurement of AV . Optical inflammation Involvement of color vision in optical
causes a decrease in AV that can sometimes neuropathies follows the de- nominated
be severe. Köllner rule, according to which patients with
primary disease predominate NO alterations
of the chromatic discrimination between
2. extrinsic motility . It is normal and in some red-green, while patients dEOS retinocoroi-
cases may acompañar- of ocular pain. disorders show more often problems of
discrimination between blue and yellow
(there are exceptions to this rule as
3. pupillary reflexes . In a neutral unilateral glaucoma
optic ropatía the affected eye it shows a
decrease of direct pupillary reflex to light
stimulus, but maintaining response
36 September 440
discromatop- open with blue-yellow sia, or
cone dystrophy Stargardt disease arranged
chromatopsia red-green) angle 8.
5. perimetry . The impact of an injury on the
visual field depends largely uncompromised
area and its location on the assembly of the
visual pathway 9. Optic neuropathies are
probably the most frequent cause of central
scotoma or trocecal centered where the
functional loss is concentrated over the
macular area or the area papilo-macular
beam.
Ophthalmological examination will focus on
examination of segmental posterior to the
eye. The anterior segment and intraocular
pressure does not tend to be affected by this
disease.
- posterior segment . For being a papilitis the
optical disc is inflamed, characterized by
elevation and zándose borrosi- dad papillary
edges. If it were retro- bulbar optic neuritis
appearance fundus would be within the
normal range.
The differential diagnosis of acute papillary
visual loss with elevation in children should
be established with the following entities:
Leber's disease, neuroretinitis, neoplastic
infiltration ca, toxic or nutritional neuropathy
and papilledema 10.
The Leber's optic neuropathy is a hereditary
optic neuropathy caused by a mutation of
mitochondrial DNA eleven. Forms affects
predominantly males and usually ma debut
between 15 and 35 years. It is characterized
by the appearance of a central visual
painless loss of an eye, followed by a loss lar
the like in the contralateral eye with the
course of the disease. With papillary
elevation microangio- patía telangiectasia
often appears. None of the above
characteristics occurred in our patient.
The neuroretinitis deposits associated
exudates at the posterior pole.
Gazette Optics
 Scientific article

The most frequent cause paediatricians tría is

the cat-scratch disease produced by Bartonella
henselae 12. Other causes such as vi- rus,
borreliosis ( borrelia bugdorfe- ri) 13 or syphilis
(VDRL, FTA-abs.) 14 was- rum ruled out
serologically. The PPD was negative fifteen.

The neoplastic infiltration more frequent is

leukemia. NO is in- filtered in 13% of leu-
processes cémicos 16. In our patient's blood
test it was normal.

The Acute toxic neuropathy It is a bilateral

process with important discromatopsia,
scotoma cecal and history of exposure to
toxic Central. The most common are lead
poisoning or drugs. Our patient had no history
of exposure to any of these agents.

determined nutritional abnormalities tional 17 They

can cause neuropathies optical aunt. The
main causes are the deficits of vitamin B 1, B 6,

B 12 or folic acid. In our case no alteration

occurred tricional nu- state.

He papiledema 18 is the bilateral papillary

elevation edge fuzziness caused by
intracranial hyperten- sion. The pa- lifting
pillar is most evident in the upper and lower
poles of the disc, usually has no pulse of the
central retinal vein, hemorrhages peripapillary
and venous dilatation. The clinical picture
associated with headache, vomiting and
neurological symptoms 19.

Figure 4. central scotoma with progressive resolution lower altitudinal scotoma.

Treatment with corticosteroids is obtained in
most cases complete resolution of CUA- dro 2. Intó weight was normalized to remove the
children should be controlled induction of
systemic side effects (hirsutis- mo, weight
gain, insomnia, hypertension, full moon
facies, etc.) and / or local level Ocular
(posterior subcapsular cataract, hypertension
ocular, etc.).
In our patient presented only a slight increase pediatric patients have not always easy to
complete because of the difficulty to dif-
medication. ferentiate acute or chronic processes to
define whether the disorder is congenital or
suffering PURCHASED Rido. Because of this
CONCLUSION exploration and resulting serology results as
crucial not only to establish a good diagnosis
Infectious optic neuritis Infantiles useful is but to assess improvement after treat- ment.
one of the most frequent causes of visual
loss count neurological ori- gene.

In resistant cases, it may be required to Through anamnesis obtendre- mos important

immunosuppressants such as azathioprine. information for diagnosis, but In our case we set the final diagnosis by
elimination,

Gazette Optics September 440 37

 Scientific article

as all required serology were negative and

clinical outcome was satisfactory.

It is common in op- tics in children neuropathies

most pa- sufficient concern bilateral involvement,
but this is not the case with our patient.

At the moment we choose not to prescribe bir

farsightedness, because you still shown patience
asymptomatic and this does not affect your
binocular vision.

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38 September 440 Gazette Optics