Annals of Indian Academy of Neurology
  Users Online: 4860 Home | About the Journal | InstructionsCurrent Issue | Back IssuesLogin      Print this page Email this page  Small font size Default font size Increase font size

CASE REPORT
Year : 2010  |  Volume : 13  |  Issue : 1  |  Page : 61-63
 

Chronic relapsing inflammatory optic neuropathy


1 Department of Medicine, Division of Neurology, Stroke Programme, University of Alberta, Canada
2 Department of Neurology, PGIMER, Chandigarh, India

Date of Submission24-Jun-2008
Date of Decision20-Aug-2008
Date of Acceptance14-Oct-2008
Date of Web Publication26-Mar-2010

Correspondence Address:
Monica Saini
Department of Medicine, University of Alberta, 11104-84 Avenue Garneau Bay, Apartment 318, Edmonton AB T6G2R4
Canada
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.61280

Rights and Permissions

 

   Abstract 

Chronic relapsing inflammatory optic neuropathy (CRION) is a recently described recurrent optic neuropathy which is steroid responsive. Several features distinguish this entity from optic neuritis associated with demyelinating disorders and connective tissue diseases. The severe degree of visual loss, persistence of pain after onset of visual loss, and recurrent episodes are unique to this disorder. We describe here a patient who presented with recurrent episodes of painful visual loss, followed by resolution of deficits, over a period of ten years. He was diagnosed as isolated optic neuritis conforming to features of CRION.


Keywords: Recurrent optic neuritis, steroid responsive


How to cite this article:
Saini M, Khurana D. Chronic relapsing inflammatory optic neuropathy. Ann Indian Acad Neurol 2010;13:61-3

How to cite this URL:
Saini M, Khurana D. Chronic relapsing inflammatory optic neuropathy. Ann Indian Acad Neurol [serial online] 2010 [cited 2019 Dec 6];13:61-3. Available from: http://www.annalsofian.org/text.asp?2010/13/1/61/61280



   Introduction Top


The syndrome comprising subacute visual loss, pain, and a clear and early response to systemic steroids is easily identifiable as an inflammatory optic neuropathy. Optic neuritis may occur as a manifestation of systemic autoimmune diseases, sarcoidosis, or central nervous system (CNS) demyelinating diseases. Chronic relapsing inflammatory optic neuropathy (CRION) is a recently described form of isolated recurrent optic neuropathy. [1] We describe here a patient with recurrent episodes of optic neuropathy over a period several years, with features conforming to the diagnosis of CRION.


   Case Report Top


A 26-year-old male presented in June 2006 with complaints of dull ocular pain, decrease in vision over 8−10 days, and painful eye movements in right eye. The pain persisted after the onset of visual loss. On probing, patient gave a history of 16−17 episodes of similar attacks occuring unilaterally over the past ten years, with a single episode involving bilateral eyes sequentially over two weeks. Each episode began with local pain increasing on eye movement and visual loss over 10−12 days. The documented visual acuity during the episodes varied from finger counting at 1 meter to only perception of light. The interval in between episodes varied from three months to three years. Each episode remitted with systemic steroids and three episodes were temporally related to steroid withdrawal. There was no history suggestive of connective tissue disease or sarcoidosis.

On examination, patient was able to count fingers at one meter with the right eye, and visual acuity in the left eye was 6/12. Right pupil was reacting sluggishly to light with a relative afferent papillary defect (RAPD). Fundus examination revealed bilateral pale discs. Remaining neurological examination was unremarkable. Perimetry revealed constriction of the visual field in the right eye, without any specific pattern. Laboratory investigations showed a normal erythrocyte sedimentation rate (ESR) and albumin: globulin ratio. The chest X-ray was normal. The Mantoux test and the autoimmune profile (LE cell, antinuclear antibody, and rheumatoid factor) were negative. The Cerebrospinal fluid (CSF) examination was normal and there was no evidence of oligoclonal bands (OCBs) in serum or CSF. Visual evoked responses revealed an increased P100 latency in the right eye (114 m sec) and were normal in the left eye. The brainstem auditory evoked response (BAER) and MRI of the brain and optic nerves (gadolinium enhanced) were normal [Figure 1],[Figure 2],[Figure 3],[Figure 4]. Previous investigations including chest x-ray and MRI brain (performed in 2003) were normal. Perimetry performed in previous three episodes showed variable field loss, which did not conform to any specific pattern.

Patient received intravenous methylprednisolone, followed by tapering doses of oral steroids. Pain subsided within two days and vision improved over two weeks to 6/12 in the right eye. At present, patient is maintained on oral deflazacort (1 mg on alternate days), and has been asymptomatic since June 2006.


   Discussion Top


CRION is a recurrent, steroid dependent optic neuritis, without evidence of any additional neurological deficits, sarcoidosis or systemic autoimmune diseases. Kidd et al., in their report of 15 patients, described a syndromic presentation of subacute optic neuropathy, prominent pain, prompt response to systemic corticosteroids, and relapse on steroid withdrawal. [1] These patients had involvement of both optic nerves with the latency (between attacks), varying from days to 14 years. The features that differentiated this group from the classical demyelinating optic neuritis, included persistence of pain after onset of visual loss, the higher degree of visual loss, and frequent relapses. None of these patients had OCBs in the CSF and their MRI of the brain was normal. Out of 30 optic nerves, 19 imaged in these 15 patients showed abnormalities on MRI including thickening, high signal intensity, or enhancement. [1]

Myers et al. have described corticosteroid dependent optic neuritis, not associated with demyelinating disease. [2] In their report of 48 patients, 32 had evidence of SLE, sarcoidosis, or other systemic autoimmune disease. Our patient had multiple attacks of steroid responsive painful optic neuropathy, each associated with significant visual loss, over a period of ten years. He has not developed any symptom suggestive of sarcoidosis or other systemic autoimmune disease, and the laboratory investigations for these entities were also negative.

The clinical presentation of our patient was similar to those described by Kidd et al., in terms of recurrent episodes of subacute onset of visual defect, significant pain and an excellent response to oral steroids. [1] In individuals with the first episode of isolated optic neuritis (ON), clinical features such as, greater degree of visual loss, prominent pain that persists following the acute phase, and a total resolution of symptoms with steroids may be indicative of a benign course. However, a complete diagnostic work-up for demyelination, autoimmune disease, and other possible causes is mandatory in these patients. The possibility of CRION should be considered only in patients with recurrent and isolated ON. Although, no specific laboratory or clinical criteria have been described for the diagnosis of CRION, clinical indicators, including higher degree of visual loss, persistence of pain after visual loss is established, and relapse on steroid withdrawal is helpful. CRION should be alluded to only after exclusion of demyelination and other autoimmune disorders.

The importance of identifying these patients has therapeutic implication as CRION is highly responsive to steroids and may mandate long-term steroid use to maintain remission. Till date, there are no systematic studies evaluating the duration and intensity of immunosuppression required in patients with CRION; the data is purely observational, based on personal experience. The experience in our patient indicates that long-term and low dose corticosteroids are an effective and safe option.

 
   References Top

1.Kidd D, Burton B, Plant GT, Graham EM. Chronic relapsing inflammatory optic neuropathy. Brain 2003;126:276-84.  Back to cited text no. 1      
2.Myers TD, Smith JR, Wertheim MS, Egan RA, Shutts WT, Rosenbaum JT. Use of corticosteroid sparing systemic immunosuppressives for the treatment of corticosteroid dependent optic neuritis not associated with demyelinating diseases. Br J Ophthal 2004;88:673-80.  Back to cited text no. 2      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 MRI findings in chronic relapsing inflammatory optic neuropathy
Authors of Document Sharma, A., Khurana, D., Kesav, P.
BMJ Case Reports. 2013;
[Pubmed]
2 Chronic relapsing inflammatory optic neuropathy: a systematic review of 122 cases reported
Axel Petzold,Gordon T. Plant
Journal of Neurology. 2013;
[Pubmed] | [DOI]
3 Recurrent subacute visual loss presenting in a 52-year-old Caucasian woman with chronic relapsing inflammatory optic neuropathy: a case report
Amrit Samra,Jason Ramtahal
Journal of Medical Case Reports. 2012; 6(1): 15
[Pubmed] | [DOI]
4 Optic neuritis: Experience from a south Indian demyelinating disease registry
Authors of Document Pandit, L., Shetty, R., Misri, Z., (...), Pai, V., Rao, R.
Neurology India. 2012;
[Pubmed]
5 Authoręs reply
Saini, M., Khurana, D.
Annals of Indian Academy of Neurology. 2010; 13(2): 152-153
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article

    

 
   Search
 
   Next article
   Previous article 
   Table of Contents
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (865 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed5098    
    Printed172    
    Emailed5    
    PDF Downloaded213    
    Comments [Add]    
    Cited by others 5    

Recommend this journal