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Show Journal of Neiiro- Ophthalmology 17( 1): 57- 59, 1997. © 1997 Lippincott- Ravcn Publishers, Philadelphia Photo Essay Magnetic Resonance Imaging of Syphilitic Optic Neuritis/ Perineuritis Larry Frohman, M. D., and Leo Wolansky, M. D. MRl, with fat suppression, of a 42- year- old woman presenting with severe brow pain and 4 days of progressive visual loss OD showed enhancement of the right optic nerve and streaky enhancement of the orbital fat. Examination had also shown considerable right optic disc edema and right relative pupillary defect. Her vision deteriorated to no light perception, with an amaurotic right pupil. After treatment with penicillin and Solu- Medrol for 14 days for what was believed to be syphilitic optic neuritis and perineuritis, she had rapid resolution of pain, no relative afferent pupillary defect, and only traces of residual disc edema. Key Words: MRl- Syphilis- Perineuritis. A 42- year- old woman presented to the general eye service on January 2, 1996, with 5 days of severe brow pain and 4 days of progressive visual loss OD. She had no increase in pain on ocular rotation. She was photophobic in the right eye. Aside from heavy menses and hypertension treated with meto-prolol, she denied any significant past medical history. She was allergic to penicillin. Manuscript received April 26, 1996; accepted May 9, 1996. From the Departments of Ophthalmology and Neurosciences and Radiology ( L. W.), UMDNJ- New Jersey Medical School, Newark, New Jersey, U. S. A. Address correspondence and reprint requests to Dr. L. Frohman at UMDNJ- New Jersey Medical School, 90 Bergen Street, sixth floor, Newark, NJ 07103, U. S. A. This study was supported by a grant from Research to Prevent Blindness, Inc. Her examination revealed that she was 20/ 200 OD, 20/ 20 OS, with absent color plates OD and 8/ 10 correct OS. We noted a right relative afferent pupillary defect. The right optic disc had marked edema and there was a trace of edema OS. We asked the patient to return the next day for ncuro-ophthalmic evaluation. FIG. 1. Initial appearance of right fundus exhibiting 360° of well- developed edema, extending into the vitreous and radially outward for 2/ 3 disc diameter, without overlying vitreous cells. The arterioles and veins were mildly tortuous. 57 58 L. FROHM AN AND L. WOLANSKY FIG. 2. Initial appearance of the left optic nerve head. Note that the disc is tilted with the nasal pole anterior. The nerve head shows mild edema present, especially nasally. FIG. 3. MR I of the orbits, TR 600, TE 25 with gadolinium, axial view. J Neiim- Opluhalmol, Vol. 17, No. I. 1997 FIG. 4. MRI of the orbits, TR 667, TE 33 with gadolinium, axial fat suppressed view. Note that in addition to the enhancement of the right optic nerve, the right orbital fat is also enhancing ( arrow). The next morning, she was counting fingers at 6 in. OD and 20/ 20 OS. Her color plates were again absent OD. There was no proptosis; the pupils were 5 mm OU, round and reactive to light, and a 3 + relative afferent pupillary defect was present OD. She had 2 mm ptosis OD. Her right upper lid was tender to deep palpation; the ocular motility was normal. The slit lamp examination and intraocular pressures were normal, as was the general neurologic examination. The right optic nerve ( Fig. 1) showed 360° of well- developed disc edema extending into the vitreous and radially outward for 2/ 3 disc diameter, without overlying vitreous cells. The arterioles and veins were mildly tortuous. The left optic nerve head was tilted with mild nasal edema ( Fig. 2). We admitted the patient for evaluation of asymmetric papilledema. An MRI scan of the brain with gadolinium was normal. The MRI of the orbits with fat suppression revealed enhancement of the right optic nerve and streaky enhancement of the orbital fat, consistent with optic neuritis/ perineuritis ( Figs. 3- 5). Hemoglobin was 6.5, with a platelet count of MRI OF SYPHILITIC OPTIC NEURTTIS/ PERINEURITIS 59 FIG. 5. MRI of the orbits, TR 600, TE 35 with gadolinium, coronal view. Note the enhancement of the right optic nerve ( arrow). 701,000. She had hypochromic/ microcytic indices and was believed to have severe iron deficiency anemia. She underwent a spinal tap that revealed an opening pressure of 300 mm H20, 5 white cells, and protein 30 mg/ dl. The serology, cultures, and Gram's stain were all negative. Her vision deteriorated that night to no light perception, with an amaurotic right pupil, where it remained for 7 days. Her RPR returned later that day, and was positive at a titer of 1: 32 dilutions, with the serum FTA- abs also p o s i t i v e . She was believed to have syphilitic optic neuritis and perineuritis, and was treated with 2 g i. v. penicillin q4h for 14 days with concomitant Solu- Mcdrol 250 mg i. v. q6h for 3 days to prevent a Hcrxheimcr's reaction, followed by 2 weeks of prednisone. Her pain resolved within 6 to 12 h. After learning the positive serologies, she adamantly refused HIV testing and any subsequent bloodwork or a repeat spinal tap. On January 11, 1996, after 7 days of therapy, she was noted to be able to count fingers at 4 feet OD. On January 22, 1996, 3 weeks after presentation, she was 20/ 200 OD and 20/ 20 OS. Her Ishihara color plates were 0/ 10 OD and 10/ 10 correct OS. The right optic disc still had mild edema over its entire circumference; the left disc had a trace of inferior edema. She was last seen on February 26, 1996, 8 weeks after her presentation, and had recovered to 20/ 20- 2 OD and 20/ 20 OS with Ishihara plates 100% correct OU. She no longer had a relative afferent pupillary defect, and there was only a trace of residual disc edema OD. .1 Ni'iiro- Opllllmlnwl, Vol. 17, No. I, 1997 |
