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Progressive Optic Neuropathy — SCE Neurology MCQ

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HardNeuro-ophthalmologyProgressive Optic NeuropathySCE Neurology

A 40-year-old man presents with painless progressive visual loss in the right eye over 3 months. Visual acuity is 6/60 on the right. There is a right RAPD and temporal disc pallor. Visual field testing shows a central scotoma. MRI shows right optic nerve enhancement. B12 and folate are normal. He is a non-smoker and drinks minimally. Anti-MOG and AQP4 antibodies are negative. CSF is normal. What investigation is most important to exclude?

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Correct answer: D — Syphilis serology

Progressive painless optic neuropathy with an enhancing optic nerve on MRI requires exclusion of inflammatory, infective, and infiltrative causes. Syphilitic optic neuritis is an important treatable cause of progressive optic neuropathy that can mimic other optic neuropathies. Syphilis serology (treponemal and non-treponemal tests) should be checked in all cases of unexplained optic neuropathy. B: Copper deficiency causes myelopathy rather than isolated optic neuropathy. C: OPA1 testing is for dominant optic atrophy but would not explain optic nerve enhancement. D: CT orbit is inferior to MRI. E: Carotid Doppler does not explain optic nerve enhancement.

Reference: ABN Neuro-ophthalmology Guidelines; BASHH Syphilis Guidelines