Papillitis (Neuroretinitis)

    • Variant of optic neuritis showing inflammation of the prelaminar optic disc
    • Called “neuroretinitis” if retinal exudates appear (“macular star figure")
    • Common causes: parainfectious autoimmune disorder, idiopathic
    • Uncommon causes: sarcoidosis, cat scratch disease, syphilis, Lyme disease, toxoplasmosis
    • Core features
      • Acute or subacute vision loss--usually monocular in adults, often binocular in children
      • Reduced visual acuity and/or nerve fiber bundle visual field defects
      • Afferent pupil defect unless both eyes are equally affected
      • Optic disc swelling--often marked and sometimes optic disc surface hemorrhages
      • Retinal hard exudates surrounding the fovea (“macular star figure”)
      • Trap: exudates may not appear ophthalmoscopically until 10 or more days after symptom onset but may be seen earlier with optical coherence tomography
    • Possible accompanying features
      • Preceding systemic viral illness
      • Vitritis
      • Retinal perivascular cuffing
    • Atypical optic neuritis
    • Ischemic optic neuropathy
    • Leber hereditary optic neuropathy
    • Infiltrative (neoplastic) optic neuropathy
    • Hypertensive optic disc edema
    • Diabetic papillopathy
    • Papilledema
    • Central retinal vein occlusion
    • Paraneoplastic optic neuropathy
    • Compressive optic neuropathy
    • Order orbit/brain MRI
      • Often normal because the disease is confined to the prelaminar optic disc, but…
      • May show thickening or enhancement of the prelaminar optic disc, orbital optic nerve, its sheath, periorbita, or neighboring meninges
      • May show scattered high T2/FLAIR signals in the brain and spinal cord white matter, suggestive of acute disseminated encephalomyelitis (ADEM), especially in children
    • Order blood count, comprehensive metabolic panel, urinalysis, acute phase reactants, chest imaging, and serologies for syphilis, Bartonella henselae IgM, Lyme, and toxoplasmosis, lumbar puncture, as appropriate
    • Order serum myelin oligodendrocyte glycoprotein (MOG) antibody if MRI shows retrobulbar inflammatory abnormalities
    • Tip: lumbar puncture can be deferred if the patient has no other neurologic manifestations and a normal brain MRI
    • Treat appropriately if an infectious cause is identified
    • Treat with corticosteroids if you have excluded infection
    • Evaluation for a specific cause of papillitis usually yields negative results
    • Elevated Bartonella henselae IgM titer prompts doxycycline treatment of cat scratch disease
    • Treatment with appropriate anti-infectives or anti-inflammatory agents may improve vision
    • Trap: evidence that Bartonella causes papillitis is weak and evidence that antibiotic treatment helps is even weaker
    • If you identify a more robust cause of papillitis, treatment with appropriate anti-infectives or anti-inflammatory agents may improve vision
    • Positive MOG antibody raises concern for recurrence of optic neuritis, but appropriate prophylaxis remains unsettled
    • In idiopathic or parainfectious papillitis, expect spontaneous or treatment-related visual improvement within weeks in 50% to 75%, but also expect recurrences; if recurrences threaten vision, consider instituting chronic low-dose prophylactic corticosteroid or other immune-modulating medication

    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