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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 918-920

Severe bilateral retrobulbar optic neuritis in a patient with psoriasis-associated sacroiliitis – A case report


Department of Vitreoretina, Sankara Eye Hospital, Guntur, Andhra Pradesh, India

Date of Submission06-Mar-2022
Date of Acceptance13-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Om Shrivastava
Department of Vitreoretina, Sankara Eye Hospital, Guntur - 522 509, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_606_22

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  Abstract 


Bilateral (B/L) simultaneous severe loss of vision and a lack of pain are indicative of an inflammatory optic neuropathy, which has been reported mostly in the systemic auto-immune disorders and defines as 'atypical' optic neuritis. The cause of inflammation in atypical optic neuritis can be an immune-related or infection or vitamin B12 deficiency. Here in this article, we report a 31-year-old male with a known case of psoriasis presented to us with complaints of sudden severe bilateral vision loss diagnosed as bilateral atypical optic neuritis because of psoriasis. This study emphasizes to recognize and monitor patients with auto-immune disorders such as psoriasis for possible development of atypical optic neuritis.

Keywords: Atypical optic neuritis, psoriasis, TNFα, visual evoked potential


How to cite this article:
Kanakamedla A, Kumar M, Shrivastava O, Sriram S, Gudimetla J. Severe bilateral retrobulbar optic neuritis in a patient with psoriasis-associated sacroiliitis – A case report. Indian J Ophthalmol Case Rep 2022;2:918-20

How to cite this URL:
Kanakamedla A, Kumar M, Shrivastava O, Sriram S, Gudimetla J. Severe bilateral retrobulbar optic neuritis in a patient with psoriasis-associated sacroiliitis – A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 30];2:918-20. Available from: https://www.ijoreports.in/text.asp?2022/2/4/918/358178



The classic presentation of optic neuritis associated with multiple sclerosis is unilateral, moderate, painful vision loss with a relative afferent pupillary defect (RAPD) and normal fundus in young adults with female preponderance.[1] Bilateral (B/L) simultaneous severe loss of vision and a lack of pain indicative of an inflammatory optic neuropathy have been reported mostly in the systemic auto-immune disorders and defined as 'atypical' optic neuritis.[2] The cause of inflammation in atypical optic neuritis can be an immune-related disease such as sarcoidosis, myelin oligodendrocyte glycoprotein (MOG)-IgG optic neuritis, neuromyelitis Optic syndrome (NMOD), or infection (e.g. Lyme disease, syphilis) or vitamin B12 deficiency.[2],[3] Determinations of the causes of optic neuritis are important for timely intervention as atypical optic neuritis can have devastating effects on the vision of the patient if not treated timely.

We report a rare case of bilateral simultaneous atypical optic neuritis with severe visual loss at presentation in a patient of psoriasis-associated sacroiliitis.


  Case Report Top


A 31-year-old male presented to our out-patient department with complaints of sudden severe bilateral vision loss since half day. He was a known case of psoriasis with right sacroiliitis and on immuno-modulators on and off for the past 3–4 years. Patients had scaly erythematous plaques over the Gluteal region, abdomen and upper limb [Figure 1]. His skin lesions were controlled with topical corticosteroids and vitamin D3 ointment; for sacroilitis, he started on methotrexate, followed by infliximab infusion, only one loading dose of which was taken 2 years back. Since past 3 months, he had recurrence of joint pain and started on methotrexate 20 mg weekly, for which he was non-compliant. On ocular evaluation, his best corrected visual acuity (BCVA) was counting figure ½ meters in both eyes (BE). He identified Ishihara color plates 8/14 with RE and 6/14 with LE. Ocular movements were full and painless; RAPD could not be dissipated as lesion was bilateral. The intra-ocular pressure was 14 mm Hg in BE. Fundus examination was normal except mild arteriolar attenuation [Figure 2]. Optical coherence tomography (OCT) LE was normal; RE showed small para-foveal PED [Figure 3]a and [Figure 3]b. He did not have any history of de-myelinating diseases. He was referred to a neuro-physician to rule out atypical MS, where pt. was advised CT chest; MR angiogram; and MRI brain, orbits, and spine along with COVID Ag and routine lab investigations. Angiogram; MRI brain, spine, and orbit; and CT chest were unrevealing. The complete blood count, ESR, LFT, RFT, coagulation profile, and serum vitamin B 12 were WNL. HIV, HBSAg, HCV, and COVID antigen tests were also non-reactive. VEP showed a irregular waveform in the right eye and prolonged P100 latency in the left eye, suggestive of the de-myelination defect [Supplementary Figure 1]. On the basis of above clinical features and investigations, diagnosis of B/L retrobulbar optic neuritis secondary to auto-immune disease was made and pt. was started on intravenous methylprednisolone 1 g/day from the next day for 3 days, followed by oral prednisolone for 11 days tapered over 3 days. After 5 days of commencement of treatment, the patient reported significant improvement in vision to 20/20 P in RE and 20/20 in LE.
Figure 1: Well-defined erythematous scaly plaque lesion of psoriasis over the skin of the abdomen and upper limb

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Figure 2: Mild arteriolar attenuation with a normal appearing fundus of both the right eye (a) and left eye (b)

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Figure 3: (a and b) Normal appearing OCT of the right eye and left eye. Small para-foveal drusenoid pigment epithelium detachment noted in the right eye

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  Discussion Top


Bilateral simultaneous optic neuritis is uncommon in adults.[2] In our patient, there was no evidence of a toxic, infectious, or neoplastic disorder. Sarcoidosis seemed unlikely in view of the negative chest CT. We have ruled out MOG-IgG optic neuritis because of the absence of optic disc edema and painful vision loss, and it is slightly more common in females.[4] NMO also seemed improbable considering the normal spinal cord MRI and no loss of RNFL in OCT on follow-up.[5] Our case presented with multiple atypical findings such as a male gender, young age, and severe painless bilateral loss of vision with a known case of psoriasis with right sacroiliitis indicative of atypical retrobulbar optic neuritis as causes of such presentation such as sarcoidosis, MOG-IgG optic neuritis, and NMOSD were ruled out. Psoriasis is a disease with complex pathogenesis in which both genetic and ambient factors have roles.[6] The disease is characterized by increased proliferation and differentiation of keratinocytes that produce various cytokines (TNFα, IL1,6), activate leukocytes that induce inflammation and epidermic cell proliferation.[6] Keratinocytes and nervous cells (optic nerve) have a common embryogenesis (from the ectoderm) and so carry the same chromosomal anomalies.[7] Studies show the importance of TNFα in the pathogenesis of psoriasis and also causing de-myelination of the optic nerve.[8] A study comparing VEP between psoriatic patients and healthy data showed that 77.3% have altered VEP (increased wave latency and/amplitude reduction of P100) as the index of sub-clinical optic neuritis because of TNFα and cytokines.[9] Another study of VEP in psoriatic patients showed a reduced p100 amplitude in 87%.[10] Our patient also has a similar alteration in the VEP pattern suggestive of optic neuritis. Few case reports of bilateral optic neuritis in auto-immune diseases such as RA and MS because of an immuno-modulator (Infliximab) are published.[11],[12] Possible mechanisms could be the inability of TNFα antagonists to pass through the blood–brain barrier to neutralize local TNFα and enhance activation of peripheral myelin-specific T cells,[13] but optic neuritis because of immuno-modulators in our patients unlikely provided that he was non-compliant for these medications. Psoriasis is skin disease that may be associated with intra-ocular immune-mediated conditions such as uveitis. The evidence of retinal or optic nerve involvement in the psoriasis is scarce. To our best knowledge, this case is the first report of severe bilateral retrobulbar optic neuritis in a patient with psoriasis.


  Conclusion Top


This case report describes an unreported atypical presentation of severe retrobulbar bilateral optic neuritis because of auto-immune disorder. It emphasises to recognize and monitor patients with auto-immune disorders such as psoriasis for possible development of atypical optic neuritis to commence the appropriate immuno-suppressive therapy and achieve a better visual outcome. We believe that this case report underscores both the clinical awareness of the possible association and the need for a further study between auto-immune diseases such as psoriasis and de-myelinating optic neuritis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bennett JL. Optic neuritis. Continuum (Minneap Minn) 2019;25:1236-64.  Back to cited text no. 1
    
2.
Chaitanya Y, Kumar A, Kaushik J, Singhal A, Dubbaka S. Severe atypical optic neuritis in a patient with pemphigus foliaceus on immunosuppressive therapy. Cureus 2021;13:e16010.  Back to cited text no. 2
    
3.
Anand OP, Choudhary SK, Gupta S. Vitamin B12 deficiency induced optic neuropathy. Delhi J Ophthalmol 2019;29:125-6.  Back to cited text no. 3
    
4.
Chen JJ, Flanagan EP, Jitprapaikulsan J, López-Chiriboga ASS, Fryer JP, Leavitt JA, et al. Myelin oligodendrocyte glycoprotein antibodypositive optic neuritis: Clinical characteristics, radiologic clues, and outcome. Am J Ophthalmol 2018;195:8-15.  Back to cited text no. 4
    
5.
Sellner J, Boggild M, Clanet M, Hintzen RQ, Illes Z, Montalban X, et al. EFNS guidelines on diagnosis and management of neuromyelitis optica. Eur J Neurol 2010;17:1019-32.  Back to cited text no. 5
    
6.
Alwan W, Nestle FO. Pathogenesis and treatment of psoriasis: exploiting pathophysiological pathways for precision medicine. Clin Exp Rheumatol. 2015; 33(5 Suppl 93):S2-S6.  Back to cited text no. 6
    
7.
Zhang X-J, He P-P, Wang Z-X. Evidence for a major psoriasis susceptibility locus at 6p21 (PSORS1) and a novel candidate region at 4q31 by genome – wide Scan in Chinese Hans. J Investigative Dermatol 2002;119:1361-6.  Back to cited text no. 7
    
8.
Jenkins HG, Ikeda H. Tumor necrosis factor causes an increase in axonal transport of protein and demyelination in the mouse optic nerve. J Neurol Sci 1992;108:99-104.  Back to cited text no. 8
    
9.
Perossini M, Turio E, Perossini T, Romagnoli M, Benedetti S, Cei G, et al. Pattern VEP alterations in psoriatic patients may indicate a sub clinic optic neuritis. Doc Ophthalmol 2005;110:203-7.  Back to cited text no. 9
    
10.
Grzybowski A, Grzybowski G, Druzdz A, Zaba R. Visual evoked potentials in patients with psoriasis vulgaris. Documenta Ophthalmologica 2001;103:187-94.  Back to cited text no. 10
    
11.
Foroozan R, Buono LM, Sergott RC, Savino PJ. Retrobulbar optic neuritis associated with infliximab. Arch Ophthalmol 2002;120:985-7.  Back to cited text no. 11
    
12.
Minami-Hori M, Tsuji H, Takahashi H, Hanada K, Iizuka H. Optic neuritis in a psoriatic arthritis patient treated by infliximab. J Dermatol 2013;40:298-9.  Back to cited text no. 12
    
13.
Robinson WH, Genovese MC, Moreland LW. Demyelinating and neurologic events reported in association with tumor necrosis factor α antagonism: By what mechanisms could tumor necrosis factor α antagonists improve rheumatoid arthritis but exacerbate multiple sclerosis? Arthritis Rheum 2001;44:1977-83.  Back to cited text no. 13
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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