Ophthalmology update for primary practitioners. Part I. Update on optic neuritis.

Optic neuritis is a common cause of acute visual loss. It is typified by sudden onset of visual impairment and pain with eye movements, followed by spontaneous recovery of vision over several months. Pathologically, optic neuritis is an acute demyelinating event affecting the optic nerve. Objective physical findings are typically few, including an afferent pupillary defect or Marcus-Gunn pupil, whereas subjective psychophysical findings abound (ie, diminished central visual acuity, color vision, decreased contrast sensitivity, and visual field abnormalities). These characteristics have made the diagnosis of optic neuritis based solely on clinical grounds disquieting to practitioner and patient alike. In addition, the fact that optic neuritis is often associated with multiple sclerosis as the first clinical manifestation of disease gives further reason for both patient and physician anxiety. The serious nature of visual loss and the consequences of making the diagnosis of optic neuritis has given rise to extensive testing and expensive treatments. This review is intended to explore our current state of knowledge with regard to (1) clinical presentation, (2) ancillary testing, (3) therapeutic intervention, and (4) associated disease, specifically the risk for multiple sclerosis in the patient who presents with an acute optic neuritis. Finally, a suggestion guide for informing the patient and addressing his or her concerns will be presented.

Rapidly progressive acute retinal necrosis secondary to herpes simplex virus, type 1.

A systemically healthy 22-year-old man presented with unilateral acute retinal necrosis (ARN) that featured diffuse retinal whitening throughout the posterior retina, exudative retinal detachment, and a visual acuity of no light perception. Diagnostic vitrectomy revealed necrotic retinal cells containing intranuclear inclusions visible with light microscopy. On electron microscopy, viral particles consistent with a herpes family virus were detected. Culture of the vitrectomy specimen showed herpes simplex, type 1 (HSV 1) and rising convalescent serum ELISA titers to HSV 1 confirmed a recent infection. This case of ARN is unusual for its severity, early macular involvement, and development of exudative retinal detachment. In addition, it represents one of the few reported cases in which HSV 1 has been confirmed by both vitreous culture and serum titers as the etiologic agent. A review of the literature suggests that posterior segment inflammatory conditions secondary to HSV 1 can be associated with exudative retinal detachment, a clinical finding that may help differentiate such conditions from other infectious causes of chorioretinitis.