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Suggest treatment for recurring optic neuritis in right eye

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Posted on Sat, 13 Jun 2015
Question: Dear Doctor, I am a 63 year old male. About 3 years ago I had the first of three attacks of optic neuritis/neuropathy in might right eye. Pain and blurring of vision: ghost imaging. Sight recovered fully in 24 hrs. On the last occasion there was a loss of vision in the right eye of half a dioptre. The opthalmologist said also a loss of colour vision in this eye . frequently have numbness and tingling in hands, sometimes feet. Had severe tremor about a year ago in one arm for three hours. Not since. Recently have severe fatigue often in afternoon. MRI showed a few lesions but were "age related". About a year ago, a year after the first, no change in MRI. Lumbar puncture normal so specialist in MS, despite initially saying the lesions were consistent with PPMS, then said didn't have MS. About two years ago doctors ruled out VitB12 and Lyme disease through tests. At that stage could perform tandem walking test perfectly. Since about a year ago my balance is very bad and I can't put one foot in front of the other- in the Tandem test- without falling. My ankles feel weak but the neurologist said my muscles are ok. In the past few months have developed severe intermittant pain in teeth or lower jaw that the dentists say is not caused by any dental problem:trigeminal neuralgia?In the past few months have fecal incontinence; did have a hemhorroid operation a year ago. Cognitive function variable. Sometimes depressed. Erectile dysfunction for some years. Some evenings restless legs syndrome very bad with uncontrollable jerking of legs. Is there anything other than MS that could explain these symptoms? Have hypertension many years: on Diovan and Zanidip. Additionally have itchy scalp: prurigo nodularis diagnosed. Constant coughing of phlegm due to post-nasal drip: pollen and mould allergy. Mild asthma. Advanced osteoarthritis in neck and left foot; constant pain from these. Not rheumatoid.
Many thanks XXXXX
doctor
Answered by Dr. Neeraj Kumar (1 hour later)
Brief Answer:
Neuromyelitis Optica, Vasculitis, Sarcoidosis

Detailed Answer:
Hello XXXX,
I have gone through your problems. You have recurrent optic neuritis of right eye, one episode of tremors, ataxia and trigeminal neuralgia.
As multiple sclerosis is commoner in female than male and onset is not so late then its possibility is less. Second demyelinating disorder may be neuromyelitis optica with involvement of optic nerve and spinal cord with paucity of MRI findings in brain.
Another possibility of some secondary cause of demyelination is to be evaluated.
Walking difficulty only in tandem gait can be normal for age but other features have to be examined and a localisation of such ataxia is to be evaluated. Ataxia may be cerebellar, sensory or sensory motor.
I will advice you to consult a neurologist and get evaluated in detail. some routine blood parameters and ophthalmological evaluation is required.
Further evaluation regarding uncommon conditions like sarcoidosis, vasculitis and nutritional deficiency should be evaluated.
Hope you found the answer satisfactory.
Do get back to me with further queries and additional reports and MRI images if possible.
Regards
Dr Neeraj Kumar
Neurologist
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Neeraj Kumar (7 hours later)
Dear Dr XXXXXXX
Thank you very much for your very helpful comments. Although I have persistent fatigue which usually comes on in the afternoon, it varies from day to day. I don't have fever, as far as I know no swollen lymph nodes and definitely no wt loss! I don't have wheezing and virtually no shortness of breath except sometimes when exposed to pollen without taking my daily Alvesco inhaler. Lung function test about two years ago were normal.
Opthalmologist did request VEP test which was normal and a field test also normal. Originally was taking Cialis for erectile dysfunction when I had first eye problems and opthalmologist suspecting NAION advised me to stop this drug which I did. Had normal chest X ray about a year ago. Have had many routine blood tests over the past few years. All normal except for low serum potassium but this is now normal taking daily potassium gluconate pills.
Did have stress-related chest pains a couple of months ago but ECG normal. Had a rash on lower legs caused by the drug Aldactone about a year ago; dermatologist did biopsy said Lymphogenic Vasculitis and probably drug related. Resolved two weeks after discontinuation of drug. Am Irish where I am aware that there is a higher incidence of Sarcoidosis. Happy to hear that the Tandem test may be difficult given my age. That is reassuring.
What should I say to the neurologist? What tests should be requested? I think that the Opthalmologist has probably done all the appropriate tests and has been very thorough but is still not sure if I have had optic neuritis or neuropathy. He demonstrated the loss of colour vision in the right eye by the Ishihara Test.The neurologist asked me about alcohol consumption: I drink about 2 medium glasses of red or white wine per day. I have normal blood sugar- am not diabetic- and don't have Vit B12 deficiency. Have had many blood tests. Have had kidney stones but not recently- seems to be helped by taking VitB6 supplement each day.Have enlarged prostate/prostatitis many years. Had gall bladder removed many years ago. Had umbelical hernia operation a year ago.
Recently my left hand fingers become sometimes completely numb after a few minutes of violin playing. This never happened before. Sometimes at night in bed get severe jerking of legs sometimes accompanied by coldness /numbness in feet. In the evening quite often when sitting for some time, restless legs syndrome affects me severely. Only started in the last six months.
Any further comments or suggestions much appreciated.
XXXX
doctor
Answered by Dr. Neeraj Kumar (4 hours later)
Brief Answer:
Atherosclerotic vascular disease as a possibility.

Detailed Answer:
Hello,

I have gone through all your problems. In light of normal VEP, normal field and NAION episodes of vision loss may be transient ischemic attacks (TIA) rather than optic neuritis. The cause of TIA may be atherosclerotic due to age and alcohol and possible dyslipidemia. Other less likely cause in your case may be cardiac.

You have normal VEP, near normal MRI and normal CSF evaluation for multiple sclerosis then this diagnosis of demyelinating disease is less likely.

Even alcohol intake for long period may cause cerebellar vermian degeneration and gait ataxia.
I will advise you to go for lipid profile and repeat investigations which are more than 6 months old. May be you have to be kept on aspirin in low dose as prophylaxis for stroke.

You need to discuss all possibilities with your neurologist.

Hope you found the answer helpful.
Regards
Dr Neeraj Kumar
Neurologist
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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Dr. Neeraj Kumar

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Suggest treatment for recurring optic neuritis in right eye

Brief Answer: Neuromyelitis Optica, Vasculitis, Sarcoidosis Detailed Answer: Hello XXXX, I have gone through your problems. You have recurrent optic neuritis of right eye, one episode of tremors, ataxia and trigeminal neuralgia. As multiple sclerosis is commoner in female than male and onset is not so late then its possibility is less. Second demyelinating disorder may be neuromyelitis optica with involvement of optic nerve and spinal cord with paucity of MRI findings in brain. Another possibility of some secondary cause of demyelination is to be evaluated. Walking difficulty only in tandem gait can be normal for age but other features have to be examined and a localisation of such ataxia is to be evaluated. Ataxia may be cerebellar, sensory or sensory motor. I will advice you to consult a neurologist and get evaluated in detail. some routine blood parameters and ophthalmological evaluation is required. Further evaluation regarding uncommon conditions like sarcoidosis, vasculitis and nutritional deficiency should be evaluated. Hope you found the answer satisfactory. Do get back to me with further queries and additional reports and MRI images if possible. Regards Dr Neeraj Kumar Neurologist