| Abstract | Optički neuritis pretežito pogađa mlađe odrasle osobe. Najčešći je uzrok akutnog unilateralnog gubitka vida u toj populaciji. No njegova važnost prije svega je u tome da nosi određeni rizik konverzije u multiplu sklerozu. To je potaknulo brojna istraživanja kako što ranije procijeniti rizik za kasniju konverziju u klinički manifestnu multiplu sklerozu, odnosno kako to usporiti ili spriječiti. Takav se oblik naziva tipičnim i tretira se kao klinički izolirani sindrom. Uzrok tipičnog optičkog neuritisa povezan je s demijelinizacijskim oštećenjima vidnog živca. Osim naglog pada vidne oštrine vrlo različitog opsega, javljaju se i poremećaji ostalih funkcija vida, kontrastne osjetljivosti, vidnog polja i kolornog vida. Gotovo u svih bolesnika javlja se retrobulbarna i periorbitna bol, izraženija pomicanjem oka, te određene zjenične nenormalnosti. Dijagnoza je klinička, no uz dodatna testiranja vidnih funkcija, poželjno je obaviti još neke pretrage. Analiza cerebrospinalnog likvora posebno je bitna kada postoje atipična obilježja optičkog neuritisa koja sugeriraju drugačiju etiologiju. Magnetska rezonancija ima značajniju prognostičku od dijagnostičke vrijednosti. Ona se jasno dokazala zasad najboljim samostalnim prediktorom rizika za kasniji razvoj multiple skleroze. U završnom istraživanju nakon 15 godina praćenja Optic Neuritis Treatment Trial grupe, 72% bolesnika s abnormalnim početnim nalazom MR mozga razvilo je MS, dok je samo 25% onih s početnim normalnim nalazom razvilo MS. Rizik je bio najizraženiji u prvih pet godina. Zbog toga se u praćenju bolesnika preporučuje raditi godišnje preglede magnetskom rezonancijom kroz najmanje pet godina. I drugi nalazi i metode, poput oligoklonalnih traka u likvoru, nekih serumskih i likvorskih biomarkera, pa i demografskih čimbenika ili anamneze pozitivne na ranija demijelinizacijska zbivanja, pokazala su određenu sposobnost predviđanja progresije bolesti, samostalno ili u kombinaciji s nalazom magnetske rezonancije. Budući da je kod tipičnog optičkog neuritisa čest spontani oporavak bez specifične terapije, nije lako odrediti koga ipak treba liječiti i na ovom području još vladaju mnoge kontroverze i stavovi nisu usuglašeni. Procijenjeni rizik pomaže u odluci. Kortikosteroidna terapija je pokazala kratkoročnu učinkovitost u visokim početnim intravenskim dozama bržim oporavkom vidnih funkcija. No dugoročna dobrobit ni oporavka vida ni sprječavanja ili odgađanja razvoja multiple skleroze nije dokazana. Tome svakako treba pridodati sve češće ukazivanje znanstvene zajednice na neurodegenerativan učinak koji kortikosteroidi mogu imati. U visoko rizičnih bolesnika valja razmotriti opciju ranog uključivanja imunomodulatornog liječenja budući da se pokazalo da u odnosu na kortikosteroide imaju dugoročnije pozitivne učinke na pojavu relapsa i smanjenje rizika od razvoja multiple skleroze, iako dugoročni protektivni utjecaj na razvoj invaliditeta nije dokazan. |
| Abstract (english) | Optic neuritis mainly affects younger adults. It is the most common cause of acute unilateral vision loss among this population. However, his importance is primarily that it carries a certain risk of conversion to multiple sclerosis. This has prompted numerous studies to assess risk of conversion to clinically definite multiple sclerosis, how to slow it down or prevent it. Such a form is termed typical and is considered as clinically isolated syndrome. Cause od typical optic neuritis is associated with demyelinating lesions of optic nerve. Apart from the sudden drop in visual acuity of various extent, there are also disturbances of other visual functions, such as contrast sensitivity, visual fields and color vision. Periorbital and retrobulbar pain, worsened by eye movement, and certain pupillar abnormalities are present in almost all patients. Diagnosis is a clinical one, still with additional visual function testing, it is desirable to perform other investigations. Cerebrospinal fluid analysis is particulary important in the case of optic neuritis with atypical features which suggests other etiologies. Magnetic resonance imaging has a more significant prognostic than diagnostic value. So far, it has been clearly demonstrated for the best independent risk predictor for later development of multiple sclerosis. In the final research of the Optic Neuritis Treatment Trial group, after 15 years of follow-up, 72% of patients with abnormal baseline brain magnetic resonance imaging developed multiple sclerosis, while only 25% of those with initial normal findings developed multiple sclerosis. Risk was most pronounced during first five years. Therefore, yearly magnetic resonance examinations are recommended, at least during first five years of follow-up. Other methods and investigations, such as oligoclonal bands in cerebrospinal fluid, some serum and cerebrospinal fluid biomarkers, even demographic factors or history suggestive of a demyelinating event in the past, showed significant predicition capability of disease progression, individually or in combination with magnetic resonance findings. Since spontaneous recovery is common in typical optic neuritis even without specific therapy, it is not easy to determine who has to be treated and in this area still exist many controversies and the attitudes are not harmonized. The estimated risk helps in the decision. Corticosteroid therapy with high initial intravenous doses showed short-term efficacy in faster recovery of visual functions. However, no long-term benefit in visual recovery, prevention or delay of the multiple sclerosis development has been demonstrated. Relating to that, it should be mentioned that scientific community is increasingly pointing out the neurodegenerative effect that corticosteroids may have. In high risk patients early immunomodulatory treatment should be considered, since it has been shown that in relation to corticosteroids there are longer-term positive effects on relapse and reduced risk of developing multiple sclerosis, although the long-term protective effect on disability development is not proven. |
