Optic neuritis in childhood is often seen after systemic infections such as viral illnesses. It can also be associated with immunizations and bee stings. The cause of the postinfectious form of viral optic neuritis is unknown. It has been speculated that an autoimmune process, triggered by a previous viral infection, results in a demyelinating injury.
Optic neuritis in children, in contrast with that in adults, is more often bilateral and associated with disc edema. Vision loss can be severe. Over half of affected children have systemic symptoms, including headache, nausea, vomiting, lethargy, or malaise.
In children, optic neuritis can occur as an isolated neurologic deficit or as a component of more generalized neurologic disease, such as acute disseminated encephalomyelitis, neuromyelitis optica, or multiple sclerosis. The relationship between optic neuritis and the later development of multiple sclerosis, which is common in adults, is less clear in children. In a small subset of children with optic neuritis, signs and symptoms consistent with multiple sclerosis develop. Older age and MRI findings extrinsic to the visual system are associated with increased risk of multiple sclerosis.
Treatment of optic neuritis in children is controversial. As vision loss is often bilateral, treatment with intravenous corticosteroids should be considered in order to hasten visual recovery. The Optic Neuritis Treatment Trial did not specifically address the issue of treatment in children, so it is difficult to apply the results of this study to these patients. See also BCSC Section 5, Neuro-Ophthalmology.
Neuroretinitis denotes inflammatory disc edema associated with a stellate pattern of exudates in the macula (macular star; Fig 26-11). Common etiologies differ by region. In North America, a common etiology is Bartonella henselae infection (cat-scratch disease). Other infectious etiologies include mumps, toxocariasis, tuberculosis, and syphilis. Patients with neuroretinitis are not at risk for development of multiple sclerosis.
Children initially suspected to have optic neuritis should be reevaluated for potential emergence of macular edema, which would reclassify the diagnosis as neuroretinitis.
Waldman AT, Stull LB, Galetta SL, Balcer LJ, Liu GT. Pediatric optic neuritis and risk of multiple sclerosis: meta-analysis of observational studies. J AAPOS. 2011;15(5):441–446.
Figure 26-11 Neuroretinitis. Inflammatory optic disc edema with a macular star.
(Courtesy of Paul Phillips, MD.)
Figure 26-12 Papilledema in the right eye of a child with idiopathic intracranial hypertension before treatment (A) and 3 months after treatment with oral acetazolamide (B). Resolution in the left eye was similar. Also see Video 26-1.
(Courtesy of Robert W. Hered, MD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.