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High rate of optic neuritis misdiagnosis found
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Nearly 60% of patients referred for optic neuritis might have been misdiagnosed, consequently receiving unnecessary treatment, according to a study.
In a Midwestern university clinic in the U.S., the medical records of patients referred for optic neuritis between 2014 and 2016 were systematically reviewed to assess the incidence of diagnostic error and to identify the main factors leading to incorrect diagnosis.
Out of 122 patients, only 49 were confirmed to have optic neuritis, and 73 had a different diagnosis, including migraine, headache with eye pain and other optic neuropathies.
The most common diagnostic errors were due to misinterpretation or failure to consider critical elements of the patient’s history, such as the frequency or the bilateral nature of vision loss episodes. In some cases, the diagnosis was biased by the presence of multiple sclerosis, to which optic neuritis is frequently related.
The second most common type of error was failure to consider alternative diagnoses, such as migraine, headache, nonarteritic anterior ischemic optic neuropathy, functional visual loss or more rare diagnoses such as neuroretinitis and optic nerve sheath meningioma.
Misinterpretation or discounting of examination findings, including eye examinations and MRI, was a third major cause of wrong diagnosis.
The authors expressed concern about the nearly 60% rate of overdiagnosis of optic neuritis in this series and suggested that clinicians should implement their findings into their clinical practice, making note of the common pitfalls that might lead to a wrong diagnosis and unnecessary treatment. Of the 73 patients for whom the diagnosis of optic neuritis was not confirmed, 12 (16%) had received a lumbar puncture, and 8 (11%) had been treated with intravenous steroids.
“Overdiagnosis in patients with alternative conditions may lead to unnecessary MRIs, lumbar punctures, treatments, loss of time and expense,” the authors wrote. – by Michela Cimberle
Disclosure: The authors reported no relevant financial disclosures.
Perspective
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Kelly Malloy, OD, FAAO
It’s always the small pieces that make the big picture. The same holds true with patient care. The small pieces of history, examination elements and diagnostic testing work together to make the diagnosis.
Stunkel and colleagues found that the majority of patients referred to neuro-ophthalmology with a diagnosis of acute optic neuritis were overdiagnosed, regardless of the referring specialty.
We cannot simplify a disease process down to one symptom, such as pain on eye movements. Understanding the underlying pathophysiological process helps the provider tease out the true cases of optic neuritis from alternate diagnoses. Optic nerve inflammation can cause initial pain on eye movements, but will be followed soon after by reduced measures of afferent optic nerve function. While a relative afferent pupillary defect is suggestive of optic neuritis, normal afferent testing is inconsistent with the diagnosis, as is a normal MRI.
Taking a thorough history, properly performing and interpreting clinical and diagnostic testing, and considering all potential differential diagnoses will help the “big picture” diagnosis become much clearer.
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