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A single copy of these materials may be reprinted for noncommercial personal use only. This site complies with the HONcode standard for trustworthy health information: verify here. This content does not have an English version. This content does not have an Arabic version. Make an appointment. Visit now. Explore now. Choose a degree. Get updates. Give today. Symptoms Symptom Checker. When to seek medical advice Get emergency medical care if you have sudden changes in vision or an injury to your eye.
Specific factors that may accompany urgent vision-related medical conditions include sudden onset of: Severe eye pain or irritation Vision loss or double vision Eye floaters, flashes of light or halos around lights Severe headache Nausea or vomiting Numbness or weakness on one side of the body Confusion, dizziness or trouble talking See a specialist in vision problems optometrist or ophthalmologist if you experience any vision problems that impair your ability to read or write comfortably, drive safely, or participate in everyday activities.
Choose a symptom Selected Select related factors View possible causes Eye problems Find possible causes of vision problems based on specific factors. Problem is Blurry distant objects Blurry nearby objects Blurry or blind spot in center of vision Blurry vision at all distances Bright zigzag lines Clouded, hazy or dim vision Double vision Fading of colors Flashes of light Glare with bright lights Halos around lights Inability to distinguish certain shades of color Loss of side vision Objects appear crooked or distorted Poor night vision Progressive expansion of shadow or curtain over visual field Seeing nonexistent things, or hallucinating Sensitivity to light Shimmering spots or stars Spots or strings floating in field of vision Tunnel vision Vision loss, partial or total.
Problem affects Both eyes One eye. Vision improves somewhat with Holding objects away from face Holding objects close to face Squinting Use of bright lighting. Onset is Gradual or progressive Recent hours to days Sudden seconds to minutes. Duration is A few minutes Usually no longer than 30 minutes. Accompanied by Confusion or trouble talking Dizziness or difficulty walking Eye pain or discomfort Eye redness Eyestrain Headache Numbness or weakness on one side of the body Other sensory disturbances Swelling around the eye.
References Walls RM, et al. Philadelphia, Pa. Accessed Oct. Palmer J, et al. Abdominal pain mimics. Emergency Medicine Clinics of North America. Zeiter D. Abdominal pain in children. Pediatric Clinics of North America. Feldman M, et al. Merck Manual Professional Version. Rochester, Minn. Kliegman RM, et al. Nelson Textbook of Pediatrics. Accessed Nov.
Zitelli BJ, et al. In contrast, a vascular event in the optic nerve would be expected to result in acute symptoms, and a neoplastic process usually evolves more slowly. Pain on eye movement: The presence of pain on eye movement is non-specific but suggests an inflammatory process affecting the globe, optic nerve or orbital contents. Diminution of colour intensity: Pale, washed-out vision with relatively little loss of visual acuity is characteristic of processes involving the optic nerve and chiasm.
Unilateral visual impairment: Visual impairment in one eye only localises the abnormality to either the eye or the optic nerve. In this test, paradoxical dilation of the pupil on direct light stimulation indicates a relative afferent pupillary defect Marcus Gunn pupil and is pathognomonic of a process that affects the optic nerve, or less commonly the retina, in one eye. Conversely, this test is usually unaffected by conditions that interfere with the transmission of light through the eye itself, such as corneal injury, cataract and processes that make the anterior chamber or the vitreous humour cloudy.
Absence of optic disc swelling: While a unilateral swollen optic nerve head definitively localises the abnormality to that optic nerve, its absence, which suggests that the pathological process is retrobulbar, is common in inflammatory optic neuropathy. Bilateral swelling of the optic nerve heads most commonly reflects raised intracranial pressure, or may be a rare manifestation of bilateral simultaneous anterior inflammatory optic neuropathy.
Differential diagnoses of unilateral visual impairment localised clinically to the optic nerve are summarised in Box 2. It most commonly occurs in the context of multiple sclerosis MS or as an idiopathic isolated event. The other cause of inflammatory optic neuritis, neuromyelitis optica NMO , is rare and far less likely. Current NMO diagnostic criteria require both optic neuritis and myelitis, although the presence of specific serum autoantibodies may raise suspicion of NMO at the time of initial presentation with an index event such as optic neuritis.
While a compressive lesion should always be considered in patients with optic neuropathy, the short temporal evolution of the symptoms argue against this possibility. Other causes of optic neuropathy — such as ischaemia, diabetes, sarcoidosis and rare infectious diseases — are unlikely in a young woman with no relevant medical history and, in comparison to idiopathic optic neuritis, are more likely to affect the anterior portion of the nerve and produce visible swelling on ophthalmoscopy. Optic neuritis is primarily a clinical diagnosis, and investigations are largely adjunctive.
Clinical features that would make a diagnosis of optic neuritis unlikely are listed in Box 3. Visual evoked potentials VEPs : In a typical clinical presentation of optic neuritis, as in this case, recording VEPs is not mandatory, but the presence of a delayed potential with preserved morphology helps confirm the diagnosis of demyelination Box 4. Blood tests: Blood tests are extremely low-yield investigations in a patient with typical symptoms and signs of optic neuritis, but full blood count, tests for erythrocyte sedimentation rate ESR , fasting glucose level and angiotensin-converting enzyme level, and screening for serum autoantibodies are routinely performed to help exclude rare causes of optic neuropathy and inflammatory diseases of the central nervous system CNS.
It may be useful in patients with atypical clinical or MRI features. Mary was referred urgently to a neurologist, with a view to urgent MRI. VEPs showed significant prolongation of the cortical potential P latency, indicating slowed conduction in the right optic nerve consistent with a demyelinating process. Results of a full blood count, tests for ESR, fasting glucose level and angiotensin-converting enzyme level, and screening of serum for autoantibodies were unremarkable.
They also showed six small areas of altered signal intensity in the supratentorial white matter affecting the periventricular and subcortical regions, one of which exhibited enhancement with the contrast agent gadolinium Box 5. The simultaneous presence of enhancing and non-enhancing brain lesions ie, actively inflamed and older lesions is sufficient information to prove dissemination in time, and Mary could be told that she has MS without waiting for a second attack.
Acute therapy: do you wait for spontaneous recovery of optic neuritis or give intravenous steroids? When do you initiate disease-modifying therapy in MS, and which therapy should you use? Optic neuritis usually resolves spontaneously over weeks to months, and simple analgesia and observation are often sufficient during the acute phase. However, there is no difference in the ultimate visual outcome in patients treated with intravenous steroids versus observation alone, 5 thus use of such therapy is controversial. The initiation of disease-modifying therapy in patients with a clinically isolated episode of optic neuritis and a diagnosis of MS based on MRI is controversial.
Blurred vision: Causes, Symptoms and Diagnosis
While long-term data favouring the treatment of patients with a clinically isolated syndrome are lacking, there is mounting circumstantial evidence that links inflammation in early MS with chronic axonal loss in the later stages of the disease, supporting the early introduction of immunomodulatory therapy.
FICTION: It is not true that intravenous steroid therapy in patients with acute optic neuritis improves long-term visual outcomes and prevents the development of optic atrophy. Disease-modifying treatments are expensive, and prescribing these for patients with a clinically isolated syndrome such as a single episode of optic neuritis in Australia is currently not subsidised by the Pharmaceutical Benefits Scheme PBS. The therapeutic options for managing MS have been expanded by the advent of new disease-modifying agents including natalizumab, which is administered as a monthly intravenous infusion, and fingolimod, the first oral agent for the condition.
Natalizumab therapy can, rarely, be associated with progressive multifocal leukoencephalopathy PML , a potentially fatal viral infection of the CNS.
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The risk of PML is determined partly by treatment duration, previous exposure to immunosuppressive therapies and the presence of serum antibodies to the causative agent, JC virus. Fingolimod, a novel immunosuppressive agent, has rare short-term cardiovascular and ophthalmic side effects bradyarrhythmia and macular oedema, respectively ; the risk of potential long-term hazards, such as serious opportunistic infection, is unknown. Periodic review 6—monthly by a neurologist is advisable to determine whether escalation of therapy is appropriate.
Subclinical disease activity may also merit escalation of therapy and can be monitored for with periodic brain MRI, but the utility of routine neuroimaging in asymptomatic patients is not well established. For women with MS, early pregnancy the first two trimesters confers moderate protection against relapse, and stable MS should not be considered a disincentive to starting a family.
Although there are no data suggesting an adverse effect of conventional immunomodulatory therapy on the developing human fetus, it is recommended that these agents be withdrawn before conception. Pregnancy should therefore ideally be planned in concert with the GP, the treating neurologist and, where relevant, the MS nurse.
The diagnosis of MS carries a significant personal, social and financial burden. Although newly diagnosed patients are often young and internet-savvy, the diagnosing neurologist is best placed to quell anxiety with a detailed explanation of the disease and its clinical spectrum. Patients whose initial presentation is with optic neuritis may have a milder disease course. It is likely that the early introduction of disease-modifying therapy will favourably alter long-term outcomes. The integration of MS nurse specialists into MS clinics in Australia has transformed the management of patients with newly diagnosed disease.
MS nurse specialists are the primary point for patient contact; they provide counselling, coordinate the implementation of services and deliver ongoing immunotherapy support.
When to seek medical advice
Minor impairment of right eye colour perception persisted. Mary continued to work full time as a sales consultant and had no immediate plans to become pregnant. Six-monthly reviews in the MS clinic were scheduled, with instructions for Mary to contact the MS nurse specialist if she developed any new, sustained neurological symptoms in the interim.
Optic neuritis immune-mediated inflammation of the optic nerve can occur in isolation or can be related to multiple sclerosis.
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Compressive optic neuropathy can be secondary to a tumour benign or malignant or secondary to a carotid-ophthalmic aneurysm. Ischaemic optic neuropathy may be arteritic usually in older patients, and there may be other features of giant cell arteritis or non-arteritic more common in patients with hypertension, diabetes mellitus, a history of smoking, and small optic discs with a small cup-to-disc ratio. Malignant infiltration of the optic nerve by glioma, leukaemia, lymphoma or carcinoma merits consideration in cases that are atypical eg, visual impairment that evolves over weeks to months.
Visual evoked potentials are recorded from occipital scalp electrodes while the patient watches a pattern-reversal stimulus black and white checks that repeatedly change phase on a television monitor. Axial fluid-attenuated inversion recovery FLAIR image showing multiple globular periventricular lesions typical of multiple sclerosis.
Gadolinium-enhanced T1-weighted axial image through the same level showing typical enhancing lesions arrowhead , indicating breakdown of the blood—brain barrier in the context of active inflammatory demyelination, and non-enhancing lesions arrow. MS is a multifocal inflammatory demyelinating disorder of the central nervous system CNS with an unknown aetiology.
Both genetic and environmental factors contribute to MS susceptibility and underlie the epidemiological variability of the disease. The disease is most common in Tasmania and least common in northern Queensland. MS has an average age of onset in the early 30s and, like many diseases that involve the immune system, is more common in women. Actively inflamed lesions are characterised by destruction of myelin, oligodendrocytes and, to a lesser extent, axons.
In relapsing MS, the clinical features correlate with the anatomic localisation of lesions, such as the optic nerve. The symptoms that accompany optic neuritis and other MS lesions are caused by focal inflammation, impaired axonal conduction due to demyelination, and axonal loss. Recovery, which is often incomplete, is the rule in early relapsing MS and is largely attributable to resolution of inflammation and remyelination.
However, there is no discernible regeneration of axons in the CNS, and loss of axons correlates with the development of irreversible disability. With increasing disease duration, areas of new focal inflammation become less common and remyelination progressively fails. Global changes affecting the white matter, characterised by activation of microglia and nerve fibre loss, become prominent. This shift in the pathophysiology over the course of the disease has implications for the timing of anti-inflammatory therapy.
Optic neuritis due to multiple sclerosis. Publication of your online response is subject to the Medical Journal of Australia 's editorial discretion.