Infiltrative (Neoplastic) Optic Neuropathy

    • Visual loss caused by cancerous infiltration of the optic nerves
    • Most common cancers are lung, breast, lymphoma, leukemia
    • Visual loss is often the only acute clinical manifestation
    • Diagnosis is confirmed by brain MRI and/or spinal fluid examination
    • Subacute monocular or binocular visual loss
    • Subnormal visual acuity and visual field loss in one or both eyes
    • Optic discs are normal, mildly elevated, or markedly elevated
    • May be the first sign of cancer or the only sign of a relapse
    • Brain MRI may show enhancement of the optic nerves or optic nerve sheaths, optic chiasm, leptomeninges, or parenchymal brain/spinal masses, but…
    • Trap: brain MRI is often normal, therefore you must move to…
    • Advanced imaging modalities, including positron emission tomography (PET,) which often find the primary lesion or metastases, but even an exhaustive search can be negative
    • Tip: MRI sometimes shows restricted diffusion of the affected optic nerve because of dense cell packing, especially in nonHodgkin lymphoma
    • Diagnosis is usually confirmed on lumbar puncture, but…
    • Trap: meningeal spread of cancer—especially lymphoma-- is hard to detect on lumbar puncture, as cells adhere to the arachnoid membrane, so…
    • Trap: spin-down cytology or flow cytometry may be positive only after several lumbar punctures, and sometimes never!
    • Optic neuritis
    • Arteritic and non-arteritic ischemic optic neuropathy
    • Compressive optic neuropathy or chiasmopathy
    • Radiation optic neuropathy
    • Paraneoplastic optic neuropathy
    • Papilledema
    • Diabetic papillopathy
    • If the diagnosis is reasonably secure, treat with high-dose intravenous corticosteroids (1gm/day for 3–5 days)
    • Refer to a neuro-oncologist, who may offer whole brain radiation and/or systemic chemotherapy
    • Visual recovery is variable
    • Death from widespread cancer regrettably occurs within a short time in solid tumor metastasis; longer survival and even remission may occur in hematologic malignancies

    Optic Nerve And Chiasm Disorders

    Drusen Optic Neuropathy Colobomatous Optic Neuropathy Optic Pit Neuropathy Morning Glory Optic Neuropathy Hypoplastic Optic Neuropathy Typical Optic Neuritis Atypical Optic Neuritis Papillitis (Neuroretinitis) Non-arteritic Ischemic Optic Neuropathy Arteritic Ischemic Optic Neuropathy Posterior Ischemic Optic Neuropathy Hypotensive Ischemic Optic Neuropathy Radiation-induced Optic Neuropathy Diabetic Papillopathy Hypertensive Optic Disc Edema Papilledema Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) Compressive Optic Neuropathy: Overview Optic Neuropathy of Graves Disease Optic Nerve Sheath Meningioma Sphenoid Meningioma Craniopharyngioma Pituitary Adenoma Pilocytic Astrocytoma (Optic Glioma) Carotid Aneurysm Suprasellar Germinoma Infiltrative (Neoplastic) Optic Neuropathy Paraneoplastic Optic Neuropathy Traumatic Optic Neuropathy Toxic Optic Neuropathy Nutritional Deficiency Optic Neuropathy Dominantly-Inherited Optic Neuropathy Leber Hereditary Optic Neuropathy Primary Open Angle Glaucoma