![]() with no nerve fiber layer odema but a central scotoma in the left eye suggestive of a left Retrobulbar Neuritis.įigure 3: Right Eye of a 49-year-old gentleman showing temporal optic nerve pallor - more than that seen at first visitįigure 4: Left Eye of a 49-year-old gentleman showing temporal optic nerve pallor - left retro bulbar neuritis Outcome Optic Nerves showed a temporal optic nerve pallor in both eyes Figure 3 and Figure 4. Within 5 months of this dose reduction in October 2016, he had a second relapse this time in the left eye with a drop-in vision to 20/60, N8, although with normal colour vision. He was regularly followed up and was in remission on treatment for one year till May 2016 after which the dose of Mycophenolate was reduced to 500 mg/day. His blood C-Reactive Protein levels were positive and hence an immunomodulator in the form of 1000 mg of Mycophenolate Mofetil was introduced into his treatment regimen to achieve an improvement of vision in both eyes to 20/20, N6 with normal colour vision by May 2015. A Visual Evoked Potential was done which showed a prolonged latency in both eyes (left more than right). He had his first relapse in April 2015 with the right eye being affected with a drop of best corrected visual acuity to Finger counting at 1 meter with ocular findings suggestive of Optic Neuritis in the right eye. He received 5 doses of pulsed Intravenous Methylprednisolone followed by an oral steroid taper and achieved in 2 months by March 2015 a best corrected visual acuity of 20/25 with a normal colour vision in the left eye. Especially done were his Anti-nuclear antibodies, Serum Anti-Aquaporin-4 auto-antibodies which were negative and Serum Angiotensin Converting Enzyme levels which were within normal limits. He was investigated thoroughly from point of view of Optic Neuritis and all investigations including his Neuro-imaging and Cerebro-spinal Fluid assessment were inconclusive towards a definite etiology for his optic Neuritis. ![]() Figure 1 and Figure 2.įigure 1: Right Eye of a 49-year-old gentleman showing temporal optic nerve pallorįigure 2: Left Eye of a 49-year-old gentleman showing optic neuritis Initial Investigations and Treatment He had a relative afferent pupillary defect (RAPD) in the left eye with a fundus examination showing a mild temporal pallor in the right eye and a mild to moderate disc hyperemia with odema and rim elevation and blurring of disc margins, nerve fiber layer odema and a mild venular tortuosity in the left eye suggesting a left optic neuritis. On examination, he has a best corrected visual acuity of 20/20, N6 in the right eye and counting fingers close to face in the left eye. Case ReportĪ 49-year-old gentleman first presented to us in January 2015 with a history of sudden painless loss of vision in the left eye since past 2-3 days. Thus CRION is a distinct entity, which is sero-negative for Anti-Aquaporin-4 auto-antibodies and recognized by and managed through its dependency on immuno-suppression with steroids and immunomodulators. CRION responds well to corticosteroids, but long-term immunosuppression is often necessary. Magnetic Resonance Imaging scans of the Brain are normal and those of the optic nerves often, but not always, show high signal abnormalities which enhance. IntroductionĬhronic Relapsing Inflammatory Optic Neuropathy is an inflammatory optic neuropathy which is frequently bilateral, often painful, and characterized by relapses and remissions. The phenotypic spectrum of Autoimmune Optic Neuropathies includes: Single Isolated Optic Neuritis (SION), Relapsing Isolated Optic Neuritis (RION), Chronic Relapsing Inflammatory Optic Neuropathy (CRION), Neuromyelitis Optica (NMO) spectrum disorder, Multiple Sclerosis associated Optic Neuritis (MSON) and Unclassified Optic Neuritis (UCON) forms.
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