13,14 As a result of the incidence of pediatric optic neuritis being approximately 10 percent of the adult rate, studying pediatric optic neuritis in a systematic manner is more difficult. Incidence estimates for adults were 5.1/100,000 in one population-based study incidence in the pediatric population is 0.5/100,000. In contrast to adult optic neuritis, optic neuritis in children is a relatively rare event. 10,11 One study found that ganglion cell layer thickness can be affected in any pediatric demyelinating disease, with thinning occurring with or without the presence of optic neuritis. Optical coherence tomography of the retinal nerve fiber layer may initially demonstrate thickening followed by thinning as optic nerve pallor develops. Visual field defects in patients with optic neuritis are variable, and some patients are too young to perform formal visual field testing with any reliability. 8,9 Optic nerve pallor commonly develops following resolution of the optic neuritis. 4,6,7 Children with optic neuritis will present more frequently with an anterior optic neuritis, rather than the retrobulbar optic neuritis more common in adults, with the majority of cases presenting with optic nerve edema (Figure 1). 4,5 However, final visual outcomes are usually very good, with visual acuities better than 20/40 in most cases. 3 Severe vision loss to worse than 20/200 is common in children with optic neuritis (90 to 95 percent), in contrast to adults in the optic neuritis treatment trial, of whom 64 percent had visual acuities better than 20/200. Pain or pain with eye movement isn’t a consistent feature of pediatric optic neuritis therefore the absence of pain doesn’t rule out optic neuritis. A meta-analysis of isolated pediatric optic neuritis studies found that 72 percent of children under the age of 10 presented with bilateral involvement, while in children older than 10 years, 70 percent presented with unilateral optic neuritis. Bilateral involvement is more common in children than in adults, and often a child will present to the emergency room only if bilateral simultaneous disease occurs, or after the second eye becomes involved. Children with optic neuritis may go without detection of the disease until one eye is incidentally covered or closed for some reason, leading the child to complain that he can’t see and prompting a visit to the ophthalmologist or the emergency room. As a result, determining exactly when vision loss occurred may not be feasible. Obtaining a clear history of the illness can be difficult, if not impossible, in children. Patients in the pediatric age range may present with different clinical characteristics than those found in adults. With pain on eye movement, often in the presence of a relative afferent pupillary defect unless the disease is bilateral and symmetric. Fundus photographs of a patient with optic neuritis in the right eye demonstrating optic nerve edema. Optic neuritis is commonly defined as the clinical presentation of decreased vision, impaired color vision or visual field defectsįigure 1. In this article, we’ll cover the various aspects of optic neuritis in pediatric patients that the ophthalmologist needs to know. Differences in presentation and underlying causes of optic neuritis in children are important to understand in order to avoid misdiagnosis and to guide neuroimaging and laboratory testing. Though this disease is more common in adults, the pediatric ophthalmologist should also be aware of it, as well as its evaluation and treatment, because associations between optic neuritis and other neuro-inflammatory syndromes may affect final visual and systemic outcomes. O ptic neuritis is defined as an inflammatory disease of the optic nerve.
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