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Acute retrobulbar neuritis occurred 24 days after an episode of Herpes zoster ophthalmicus in an otherwise healthy, 19-year-old man. Profound visual loss with consecutive optic atrophy ensued. Neurologic evaluation was normal and supported the presumptive diagnosis of parainfectious Herpes zoster retrobulbar neuritis.
In most patients, idiopathic optic neuritis remits spontaneously. Among those in whom it does not are patients with systemic lupus erythematosus, who often respond to pulse methylprednisolone. This subset of patients may be expanded to patients with other autoimmune phenomena, as in the case of a young woman who had myasthenia gravis and other laboratory evidence of autoimmunity. She had permanently lost vision in the right eye without treatment of optic neuritis, but in a later similar episode the left eye responded to pulse methylprednisolone after failing to respond to orally administered prednisone.
Time-consuming and complicated electrophysiological methods need only be applied in unclear cases of optic neuritis. In the majority of patients it is possible to demonstrate opticus conduction disturbance with exact clinical subjective and objective tests. Some neuroophthalmological investigations that are well-suited for routine use are described more closely. Our own investigations of 190 patients demonstrated - in accordance with the modern medical literature - that the nowadays usual therapeutic measures do not influence the course of an optic neuritis essentially.
The effectiveness of hyperbaric oxygenation (HBO) in a multiple modality therapy versus the conventional treatment of patients with facial neuritis was investigated. HBO was used in the treatment of 42 patients. Twenty-nine patients with a similar picture of the diseases treated by conventional methods without the use of HBO constituted the control group. The inclusion of hyperbaric oxygenation in to the multiple modality treatment of patients with facial neuritis increased the efficacy of therapy and reduced the period needed for the restoration of the function of the damaged nerve.
Brachial neuritis is an unusual syndrome of unknown etiology that can be confused with other causes of pain or weakness, or both, of the shoulder and arm. It is important to distinguish this disorder because of its dramatic symptoms and relatively good prognosis. Sharp pain, usually in the elbow or shoulder, marks the onset of brachial neuritis, but is relatively short-lived. Weakness generally occurs as the pain is subsiding and most frequently involves the deltoid, spinati, serratus anterior, biceps, and triceps. Paresthesias, atrophy, and sensory loss are inconstant features. Electromyographic findings of fibrillation potentials and positive waves characteristically are found in a pattern indicating combined nerve-root and peripheral nerve involvement. Electromyography more frequently than clinical examination shows that the lesion is bilateral, and also is of both diagnostic and prognostic value. Other laboratory studies serve only to exclude other causes of shoulder pain. The clinical course is variable, but in 90 per cent of patients complete recovery occurs within three years. Recurrences are uncommon.
Sixteen patients whose chief complaint was ocular or periocular pain were diagnosed as having occipital neuritis. All but one had significant relief of pain from one or more injections of an anesthetic in the vicinity of the greater occipital nerve. They were subsequently treated with anti-inflammatory measures. From these cases definitions of significant tenderness and success of treatment were developed. These observations form a basis for a current double-blind study designed to establish a relationship between ocular pain and occipital neuritis.
In 61 of 300 patients suffering from multiple sclerosis, disease onset was retrobulbar optical neuritis. Comparing the clinical data of these patients with those of the remaining 239 cases, the following typical features were observed: in patients with optical neuropathy, disease onset is more frequently acute and course, in the early years of the disease, is in fits and starts. Recurrence frequency is higher in these patients but not significantly so. Prognosis, deduced from the analysis of degrees of invalidity, does not differ substantially between the two groups. Current techniques of diagnosing multiple sclerosis in patients with retrobulbar optical neuritis are also discussed.
Two patients exhibiting bitemporal hemianopia due to chiasmal optic neuritis with pathological confirmation of noncompressive lesions are presented; the first due to a chronic, idiopathic demyelinating process, and the second a result of ethchlorvynol (Placidyl) toxicity. The literature regarding chiasmal optic neuritis is reviewed, and a discussion of other noncompressive causes of bitemporal hemianopia is presented.
Edema and increased endoneurial fluid pressure (EFP) accompany the inflammatory process in experimental allergic neuritis. EFP was measured at regular intervals 6 to 21 days after intradermal inoculation of Lewis rats with an emulsion of peripheral nerve in complete Freund's adjuvant. Control rats received similar injections of an emulsion containing all other ingredients, except peripheral nerve. Altered vascular permeability was illustrated by leakage of horseradish peroxidase into rat sciatic nerve endoneurial space as early as 10 days after inoculation. A difference in EFP between controls and test animals became apparent after 11 days, and highest values were obtained 12 to 16 days postinoculation. Nerves were excised for histologic examination after EFP measurement. Severe endoneurial edema was present after 12 days and was associated with appreciable inflammatory cell infiltration. Inflammatory cells were clustered around small vessels and also were numerous in the subperineurial space which was expanded by edema. Degranulation of mast cells was also noted in association with edema and inflammation. Immunoperoxidase staining revealed immunoglobulin in the subperineurial and perivascular spaces 10 to 12 days postinoculation, but not in sections 6 to 9 days (postinoculation). These findings suggest suggest that altered vascular permeability is the earliest morphologic change in experimental allergic neuritis, followed by accumulation of antibody-containing edema fluid, penetration of the endoneurium by inflammatory cells, and increased EFP.
Patients with multiple sclerosis (MS) and a history of optic neuritis were compared with MS patients who had no such history for other illnesses among themselves and their family members. Significantly more of the patients with a history of optic neuritis than of those without (70% v. 41%) were diabetic or reported that at least one first- or second-degree relative had diabetes mellitus. No differences were found with regard to any other illnesses.
Three cases of chiasmal optic neuritis are described with bitemporal visual field loss and enlargement of the optic chiasm as demonstrated by computed tomography (CT). Exploratory craniotomies were performed in two of the patients, but no tumor was found. After corticosteroid treatment, all three patients experienced virtually complete restoration of normal vision. Although the CT presentation in these patients was indistinguishable from that of a chiasmal glioma, the clinical presentation of acute visual loss in an older child or adult should suggest chiasmal optic neuritis. A period of observation, with or without a trial of corticosteroids, might permit the latter diagnosis and obviate exploratory craniotomy.
Two cases of optic nerve neuritis are reported. The first had typical clinical symptoms and the other had an atypical course. In the case of the first patient an astrocytoma was found in the right frontal lobe. The aetiology of the second case was a meningioma of the tuberculum sellae. The clinical findings in our cases are discussed with regard to 58 cases in the literature. In all cases of optic neuritis with typical and atypical course a tumor of the central nervous system must always be taken into consideration.
Sixty-two ulnar nerves belonging to 44 patients with early neuritis were studied to assess the benefits offered by medial epicondylectomy and external decompression in addition to steroid therapy. The patients were randomly allocated to the surgical or the medical group. In those cases where there was bilateral involvement, surgery was carried out only on one side. All cases were assessed prior to treatment, and at predetermined intervals following treatment. This study presents the results after a 12-month follow-up. There was statistically significant improvement in both groups following treatment as assessed by improvement in motor and sensory functions and in the reduction of pain and tenderness. The study, however, failed to demonstrate any added benefit with surgical intervention as compared to steroid therapy alone in the treatment of early ulnar neuritis.
Temporal contrast sensitivity was measured in patients with optic neuritis and anisometropic amblyopia. In optic neuritis, attenuated sensitivity was detected at all frequency ranges; however, its degree was more severe than that of retinal diseases even when visual acuity was the same. At the convalescent stage, the low-frequency sensitivity was restored first, and high-frequency loss was observed even when the visual acuity was restored to 1.0. Two amblyopic patients showed attenuated sensitivity at high- and intermediate-frequency ranges, and in one case all frequency sensitivity attenuated. Three other patients showed normal sensitivity. By occlusion of the nonamblyopic eye, recovery of sensitivity was observed in one patient, whose visual acuity improved.
Static perimetry of the central visual field was performed using Harms apparatus and Friedmann's analyser in 20 M.S. patients with subclinical optic neuritis at least for one eye. Sub-clinical optic neuritis was defined as delayed or absent pattern reversal visual evoked potentials (VEPs) associated with normal routine ophthalmological examination (visual acuity, optic fundi, colour vision, kinetic perimetry). Results in patients were compared to data obtained in 22 control subjects, matched for age. A highly significant loss of mean retinal sensitivity was observed in the 20 central degrees of the visual field of eyes with abnormal VEPs. Central relative scotomata were disclosed in 18 of the 33 eyes with abnormal VEPs. Static perimetry was found to be abnormal, for at least one eye, in 15 in the 20 M.S. patients. Thus abnormal VEPs in M.S. are often associated to a lowered capacity to detect a stationary stimulus in the central visual field. The Friedmann's visual field analyser allows a quick and reliable evaluation of the loss of retinal sensitivity in M.S. patients.
The latencies of transient potential (TP) and steady state potentials (SSP) were compared in patients with definite or probable retrobulbar neuritis and in normal controls. TP show different components whereas SSP being simple sinusoidal responses. Only the comparison of the responses elicited by stimulation with different frequencies may allow for measurement of SSP latencies. For this comparison we used a new method based upon a model suggested by Diamond (4). It was modified for clinical application. Its principles are described in detail. For its clinical application two aspects were of special interest: 1. modification of the supposed model because of impaired conduction in the demyelinated optic nerve and 2. additional information by SSP in cases of probable retrobulbar neuritis if an altered TP configuration prevents latency measurements.
A case of a 4-year-old white girl affected with unilateral optic neuritis and acute cerebellar ataxia is presented. Visual evoked potentials (VEP) demonstrated prolonged latency of the right optic nerve as well as the left retrochiasmal pathways. This child had complete resolution of the cerebellar ataxia and the optic neuritis with return to normal of her VEP. This case is an example of a disease characterized by a single episode of multifocal involvement of the CNS differing from diffuse encephalomyelitis and multiple sclerosis.
The supraliminal contrast sensitivity functions in patients with recovered optic neuritis were classified into three function types: 1) type with a decrease in sensitivity in the high and an increase in the low spatial frequency region, 2) type with flat shape as found in normal subjects, and 3) type with a decrease in the low and an increase in the high frequency region. These abnormal functions may be explained by an inhibitory interaction between two parallel channels of high and low frequency, which may have a dependence on the most central and the paracentral region in the visual fields, respectively. The measurements of the supraliminal contrast sensitivity functions are clinically useful for understanding the visual processes in cases with recovered optic neuritis.