Taiwan Journal of Ophthalmology 2 (2012) 112113

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Taiwan Journal of Ophthalmology

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Letter to the Editor

Bilateral papillitis associated with chiasmal optic neuritis

Dear Editor and May-Yung Yen.1 The authors have described the clinical
presentations and the visual outcome of three cases of chiasmal
We read with great interest the article entitled Chiasmal optic optic neuritis. All three cases are female, with long term multiple
neuritis: A report of three cases by Shih-Yun Lee, An-Guor Wang, sclerosis and previous episodes of unilateral or bilateral optic

Fig. 1. Fundus examination showed right (A) and left (B) papilledema before the initiation of methylprednisolone treatment. MRI showed abnormal high signal change of optic
chiasm on coronal (D) FLAIR imaging; and abnormal enhancement of bilateral posterior intraorbital optic nerves (C). Visual eld examination (Octopus static perimetry) with
30 degree low vision program ve days after methylprednisolone treatment (E and F).

2211-5056/$ see front matter Copyright 2012, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.
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 Letter to the Editor / Taiwan Journal of Ophthalmology 2 (2012) 112113
neuritis. Also, in all of these cases, optic neuritis was presented as
retrobulbar optic neuritis, without apparent inammatory
changes in the optic disc on fundus examination. Recently, we
encountered a case with bilateral optic neuritis associated with
chiasmal involvement. In contrast to the above cases, our patient
was a young male, without any history of systemic disease,
including multiple sclerosis, who presented with bilateral papilli-
tis; it was his rst episode of attack. We believe that the presenta-
tion of our case may supplement the above cases and help to
elucidate the variable clinical characteristics of chiasmal optic
neuritis.
Case report
A 25-year-old male was seen after progressive, bilateral visual
loss in 2 weeks. He had light perception in his right eye and doubt-
ful light perception in his left eye. Apart from mild cough with fever
for 1 day, he denied any systemic disease or trauma event prior to
this episode. The patients initial complaint was mild pain during
eye movement and periocular fullness sensation in the morning
for 2 to 3 days. Visual disturbance rst took place in his right eye,
then in his left eye in 1 week. Fundus examination showed bilateral
disc edema and hemorrhage (Figs. 1A and 1B). There were no signif-
icant ndings on physical or neurological examination. Under the
impression of bilateral optic neuritis, the patient was treated with
intravenous methylprednisolone 250 mg every 6 hours for 3 days,
followed by oral prednisolone for another 2 weeks. Magnetic reso-
nance imaging (MRI) showed an abnormal high signal change in
the optic chiasm on coronal FLAIR imaging and abnormal enhance-
ment of bilateral posterior intraorbital optic nerves and sheath,
more on the left (Figs. 1C and 1D). Visual eld examination 5
days after the initiation of corticosteroid treatment revealed
a near total scotoma, with slight sparing of the nasal eld in the
right eye, and a temporal hemianopsia with less nasal involvement
in the left eye (Figs. 1E and 1F). After a full course of corticosteroid
treatment, disc swelling and hemorrhage subsided gradually. The
visual acuity improved to 6/12 in his right eye and 6/30 in his left
eye. A signicant improvement in visual eld examination was
also noted. Laboratory examination, such as anti-nuclear antibody
(ANA), anti-ds DNA, anti-cardiolipin IgG, erythrocyte sedimenta-
tion rate (ESR), C-reactive protein (CRP), rheumatic arthritis (RA),
C3, C4, vitamin-B12, and folate were checked and were within
the normal range. Serologic tests for syphilis (rapid plasma reagin)
and human immunodeciency virus (HIV) were negative. Only
mild leukocytosis was noted, yet no clinical evidence of infection
was found.
The initial diagnosis of our patient was thought to be bilateral
optic neuritis. However, the subsequent visual eld and MRI exam-
inations revealed the existence of chiasmal optic neuritis. Although
bilateral involvement may comprise up to 16.4% (Singapore)2 and
34.9% (Taiwan)3 in idiopathic optic neuritis of Asian patients, the
association of chiasmal optic neuritis with bilateral optic neuritis
has rarely been reported in the literature. By a sequential examina-
tion of MRI in a patient with idiopathic bilateral optic neuritis,
113
Soltau and Hart found a chiasmal inammation with asymmetric
bilateral optic nerve and tract involvement.4 They hypothesized
that in these cases, the bilateral optic neuritis may originate from
the chiasmal portion, with extension of inammation along the
bilateral optic nerves. In an 8-year-old girl with bilateral papillitis,
Beiran et al also identied a chiasmal involvement in the MRI
examination.5 Like our case, both of those patients also suffered
initial profound visual impairment, but with good recovery after
intravenous corticosteroid pulse therapy, followed by oral
prednisolone.
In conclusion, the addition of this case further supports, that in
patients with sequential or simultaneous bilateral optic neuritis,
chiasmal optic neuritis must be taken into consideration; as
suggested by the authors, detailed MRI examination of the optic
chiasma is mandatory for an accurate diagnosis.
References
1. Lee SY, Wang AG, Yen MY. Chiasmal optic neuritis: a report of three cases. Taiwan
J Ophthalmol 2012;2:6872.
2. Lim SA, Goh KY, Tow S, Fu E, Wong TY, Seah A, et al. Optic neuritis in Singapore.
Singapore Med J 2008;49:66771.
3. Lin YC, Yen MY, Hsu WM, Lee HC, Wang AG. Low conversion rate to multiple scle-
rosis in idiopathic optic neuritis patients in Taiwan. Jpn J Ophthalmol 2006;50:
1705.
4. Soltau JB, Hart Jr WM. Bilateral optic neuritis originating in a single chiasmal
lesion. A case report. J Neuroophthalmol 1996;16:913.
5. Beiran I, Krasnitz I, Zimhoni-Eibsitz M, Gelfand YA, Miller B. Paediatric chiasmal
neuritistypical of post-Epstein-Barr virus infection? Acta Ophthalmol Scand
2000;78:2267.
Tze-Yi Chan
Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial
Hospital, Taipei, Taiwan
Yu-Chi Lin
Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial
Hospital, Taipei, Taiwan
College of Medicine, Fu Jen Catholic University,
New Taipei City, Taiwan
Cheng-Kuo Cheng*
Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial
Hospital, Taipei, Taiwan
College of Medicine, Fu Jen Catholic University,
New Taipei City, Taiwan
College of Medicine, National Taiwan University, Taipei, Taiwan
* Corresponding author. Department of Ophthalmology, Shin Kong
Wu Ho-Su Memorial Hospital, 95, Wen-Chang Road,
Shih-Lin District, Taipei 11101, Taiwan.
E-mail address: chengkuocheng.md@gmail.com
6 February 2012
Available online 17 July 2012