YAJEM-159400; No of Pages 3

American Journal of Emergency Medicine xxx (xxxx) xxx

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Failure of painful eye movements to respond to topical anesthetics

supports the diagnosis of optic neuritis
Dietrich Jehle a,c,⁎, Mary Claire Lark b, Clay O'Brien c
a
Grand Strand Medical Center, Department of Emergency Medicine, Myrtle Beach, SC 29572, United States of America
b
Medical University of South Carolina, Charleston, SC 29425, United States of America
c
University of South Carolina, School of Medicine, Columbia, SC 29209, United States of America

Keywords:
Topical anesthetic
Optic neuritis

1. Case report
1.1. Why should an emergency physician be aware of this?
Optic neuritis should be considered when eye pain is present, even
in the context of a relatively normal eye exam. Eye pain without relief
of pain with topical anesthetics such as Tetracaine should rule out exter-
nal causes and other deeper eye pathology should be considered. MRI
with gadolinium contrast is the best test used to definitively diagnose
optic neuritis.
2. Introduction
Eye pain is a common emergency department complaint with a
broad differential; history and physical exam help to narrow this.
Optic neuritis typically has some physical exam findings suggestive of
the diagnosis, but can also present with a normal exam. Presented in
this report are two cases of optic neuritis with minimally abnormal
ophthalmic exams. The lack of response to eye pain on movement
with topical anesthetics may be an aid to diagnosing optic neuritis. In
addition, the typical presentation and diagnosing of optic neuritis is
also reviewed.
3. Case report
day course. The pain was intensified with eye movement. Blurred pe-
ripheral vision was noted on the morning of the 3rd day.
On physical exam the visual acuity was 20/30 in both eyes, however
peripheral acuity was decreased. Vital signs were: temperature 36.6 °C
(98 °F), blood pressure 209/108 mm/Hg, pulse 108 beats/min, respira-
tory rate 16 breaths/min. Extra-ocular movements were intact, pupils
were equal round and reactive to light. No conjunctival injection was
noted. Fundoscopic exam showed no blurring of discs. There was ten-
derness to palpation of the left eye. Intraocular pressure was normal
in both eyes. There was no change in eye pain with Tetracaine adminis-
tration. Ophthalmology saw the patient in the ED and found a relatively
normal physical exam as well, other than the patient noting slightly
darker color seen from the left eye on gross color vision testing and di-
minished peripheral acuity.
Ultrasound of the left eye was done which did not reveal any abnor-
mality of the eye or retina. Chemistry panel was normal. MRI with gad-
olinium contrast of the orbit and MRI of the brain showed focal
enhancement of the mid to distal left optic nerve consistent with
optic neuritis. There were no additional lesions consistent with multi-
ple sclerosis.
The patient was given a dose of oral Lisinopril, which she takes as an
outpatient for the elevated blood pressure, which resulted in improve-
ment of her blood pressure. She was admitted to the hospital for further
workup of the etiology of her optic neuritis and was started on an IV ste-
roid infusion.

3.1. Patient A
A 46-year-old female with a past medical history of hypertension
and hyperlipidemia sent in by an optometrist with left eye pain onset
3 days prior. She described the pain as retro-orbital throbbing that
was gradual in onset with progressive worsening of pain over the 3
⁎ Corresponding author at: Emergency Medicine Residency Program Director,
Academic Chair, Emergency Medicine, Grand Strand Medical Center, Myrtle Beach,
South Carolina, Professor of Emergency Medicine, VCOM, Clinical Professor of Surgery,
University of South Carolina, Emeritus Professor of Emergency Medicine, University at
Buffalo, 809 82nd Ave, Myrtle Beach, SC 29572, United States of America.
E-mail address: djehle@roadrunner.com (D. Jehle).
3.2. Patient B
A 37 year old female presented to the emergency department with a
5 day history of blurry vision and right eye pain worse with movement.
The patient was admitted to the hospital 1 month prior with bilateral
optic neuritis. She presented with a 2 day history of intermittent bilat-
eral blindness. She also reported right sided retro-orbital pain with
eye movement beginning a few days prior to onset of the blindness.
She had a normal initial workup including non-contrast MRI. A subse-
quent MRI with contrast showed contrast enhancement of both optic
nerves consistent with bilateral optic neuritis. The patient was treated

Please cite this article as: D. Jehle, M.C. Lark and C. O'Brien, Failure of painful eye movements to respond to topical anesthetics supports the
diagnosis of optic n..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2020.09.031
D. Jehle, M.C. Lark and C. O'Brien
with IV methylprednisone and was noted to have 20/20 visual acuity on
discharge.
The patient's vital signs on physical exam were: temperature 36.8 °C
(98.4 °F), blood pressure 156/94 mm/Hg, pulse 97 beats/min, respira-
tory rate 18 breaths/min. Extra-ocular movements were intact. Visual
acuity was 20/25 in the left eye and 20/30 in the right. Pupils were
equal, round and reactive to light. Fundoscopic exam showed normal
disc margins. No conjunctival injection was present. Of note, on exami-
nation 1 month prior the patient did have disc hyperemia and pupils
were 8 mm and sluggishly reactive to light.
MRI with gadolinium contrast showed enhancement of the mid to
distal segment of the right optic nerve sparing the optic nerve head.
Mild optic nerve swelling was present as well. This study was com-
pared to the MRI from the previous admission in which there was in-
volvement of the optic nerve head. Signal enhancement was also
present in the mid to distal left optic nerve including the optic
nerve head, however this was to a lesser extent compared to the ear-
lier study.
The patient was admitted to the hospital for repeat course of IV
steroids.
4. Discussion
While optic neuritis with a relatively normal eye exam has been doc-
umented previously, it is less common and can make it more difficult to
diagnose. Pain relief, or lack thereof, using topical anesthetics has not
been documented in association with the diagnosis of optic neuritis,
and we found that this may help aid in diagnosing by effectively ruling
out anterior-ocular causes of eye pain. Tetracaine was used in both pa-
tients and did not result in any decrease in pain.
Optic neuritis is inflammation and demyelination of the optic nerve
caused by an autoimmune response. This condition typically presents
with pain with eye movement, first, followed by monocular loss of vi-
sion [1,2]. Most cases occur in women between the ages of 20–40
with 70% of all cases being women [3-5]. Optic neuritis is associated
with multiple sclerosis (MS) and is the presenting symptom in 25% of
cases and occurs in 70% of MS patients at some time during the illness
[6,7]. The probability of developing MS within 15 years of optic neuritis
onset is 50% [8].
2
American Journal of Emergency Medicine xxx (xxxx) xxx
The most common acute symptoms of optic neuritis are vision loss
and eye pain. The vision loss is typically progressive, unilateral, and in-
cludes blurring and dyschromatopsia. In both of these cases eye pain
preceded any visual loss. This is also a less common finding in acute
optic neuritis; however, the severity of symptoms varies greatly [6].
This presentation of optic neuritis has been documented as normal,
as pain can precede visual symptoms in up to 39% of cases [1].
These symptoms progress over hours to days, peaking within 1–2
weeks [9]. If symptoms continue to worsen after this time another eti-
ology should be considered [10]. Most patients with optic neuritis
present with unilateral symptoms. Vision loss is predominately cen-
tral, occurring in about 90% of patients [10,11]. Presenting visual acu-
ity ranged from 20/20 with mild visual field defects to no light
perception. Initial visual acuity was better than 20/200 in 64% in the
optic neuritis treatment trial (ONTT), with 35% 20/40 or better [1].
Eleven percent of patients had visual acuity of 20/20 and 3% had no
light perception [12]. In 95% of cases, any loss of vision resolves,
and, over time, visual acuity in the affected eye(s) is nearly completely
recovered [2]. In one study, investigating visual function in the af-
fected eye 15 years after optic neuritis found that 72% of patients
had visual acuities of 20/20 and only 8.7% of patients had a visual acu-
ity of 20/40 or worse in the affected eye [7,13]. Eye pain occurs in 92%
of patients [1]. The pain is typically periocular and/or retro-orbital, and
is usually worse with eye movement [9,11]. The onset of pain can co-
incide or precede visual acuity changes, and typically improves with
vision changes as well [9,11].
Other physical exam findings include an afferent pupillary defect,
which is present in almost all unilateral cases with blindness [1].
About 1/3 of cases will have hyperemia, disk swelling and/or blurring
of disk margins (1,11). Patients with early-stage retrobulbar neuritis
will present with a normal optic disc but can still experience vision
loss. [14] Loss of color vision out of proportion to visual acuity loss is
specific to an optic nerve pathology [11]. In about 10% of optic neuritis
cases symptoms occur in both eyes, and concurrent bilateral optic neu-
ritis occurs in about 20% of relapsing cases [15,16].
To diagnose optic neuritis, an MRI of the brain and orbit is indicated
using gadolinium contrast. Contrast enhancement of optic nerve is re-
ported in 94% of acute optic neuritis cases [9]. MRI of the brain should
be included to rule out any other lesions consistent with multiple
sclerosis.
In patient B, her initial MRI performed at a transferring facility was
normal. This is because it was non-contrast study. Subsequent MRI's
using contrast were positive for contrast uptake in the optic nerves con-
sistent with optic neuritis. Contrast enhanced brain and orbit MRI are
the preferred method of diagnosing optic neuritis.
Of note, patient A had received an MMR vaccine 1–2 months prior to
onset of the episode. Neurologic complications (i.e. optic neuritis) asso-
ciated with immunization such as the MMR vaccine, have been docu-
mented, but the onset of optic neuritis following immunization is
usually within 4 to 5 days [17,18]. Patient B was 4 weeks post partum
when she was first diagnosed with optic neuritis and had gestational di-
abetes complicating her pregnancy. Whether or not this could be re-
lated to the onset of optic neuritis is unknown.
5. Conclusion
Administration of tetracaine was unable to relieve any symptoms in
patients A or B. Pain relief after a topical anesthetic (e.g. tetracaine) has
been applied may suggest a diagnosis other than optic neuritis. Tetra-
caine has the potential to be a valuable tool in ruling out conditions
that may present similarly to optic neuritis.
HCA disclaimer
“This research was supported (in whole or in part) by HCA and/or an
HCA affiliated entity. The views expressed in this publication represent
D. Jehle, M.C. Lark and C. O'Brien
those of the author(s) and do not necessarily represent the official views
of HCA or any of its affiliated entities.”
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