Papillitis is the name given to a subtype of optic neuritis in which the optic nerve is damaged along its course at the so-called optic nerve head (papilla). Papillitis causes visual disturbances up to complete loss of vision.
What is papillitis?
Optic neuritis is differentiated into several subtypes depending on the location of the inflammation. Papillitis is said to occur when the diseased portion of the optic nerve is localized in the eye. The inflammatory reactions manifest themselves in the optic nerve head – the place where the nerve cords of the inner retinal layer bundle and emerge from the eye as the optic nerve. The optic nerve is responsible for transmitting visual information signals to the brain. The inflammation-induced slowing of information transmission therefore leads to a reduction in vision. The inflammation can also cause permanent damage to the optic nerve. The highest incidence of papillitis is in adults between 20 and 50 years of age. Statistically, however, women develop the disease more often than men.
Causes
The specific cause of inflammation of the optic nerve head cannot be clearly determined in the vast majority of cases. Papillitis can be causally attributed to inflammatory diseases, allergies, and autoimmune diseases, but also to infections or poisoning. Thus, the spread of an inflammatory focus from neighboring anatomical structures, such as the orbit, paranasal sinuses, or skull base, can lead to papillitis. In children, inflammation of the optic nerve head usually occurs in association with an upper respiratory tract infection. In adults, on the other hand, it is usually associated with inflammation of the vascular walls (vasculitis) or the brain (encephalitis). Bacterial and viral infections (for example, typhus, syphilis, malaria, and diphtheria) can also cause inflammation of the papilla. Autoimmune diseases such as Crohn’s disease, Wegener’s disease or lupus erythematosus are also considered triggers. Other causes include metabolic diseases (for example, diabetes mellitus) and poisoning with methanol, quinine, or heavy metals.
Symptoms, complaints, and signs
Typical symptoms in papillitis are acute visual disturbances. Affected individuals exhibit reduced visual acuity and decreased perception of colors and contrasts. Furthermore, central visual field loss (central scotoma) is possible. In this quasi-blindness, the space visually captured by the non-moving eye appears as a black-grey spot in the center. In most cases, only one of the two eyes is affected by the inflammation and the associated visual impairment. In addition, patients complain of a painful feeling of pressure at the back of the eyeball. The inflammatory processes may also affect the motor nerves, resulting in pain during eye movement. Likewise, painful sensitivity to pressure and light may occur. The spread of inflammatory pain can also trigger deep-seated headaches. Symptoms may be aggravated by increased body temperature as a result of hot baths, saunas, or exercise.
Diagnosis and course of the disease
The course of the disease of papillitis varies. Usually, as the inflammation heals, there is also a decrease in symptoms. Despite acceleration of the healing process with medication, several weeks to months may pass before freedom from symptoms is achieved. Severe inflammations, on the other hand, can lead to permanent visual defects or blindness of the affected eye due to permanent damage to the optic nerve head. The diagnosis of optic neuritis is generally difficult. First of all, the patient’s medical history is clarified. During the clinical examination, the affected eye is inspected. Pain sensitivity can be tested by manually applying pressure to the eyeball. During the ophthalmoscopic examination with the ophthalmoscope, a slightly swollen, blurred and reddened optic nerve head can be seen. Using the alternating exposure test, the pupillary reaction can be determined. Due to the inflammation, the pupillary reflex of the affected eye is sluggish, as evidenced by a conspicuously dilated pupil. In addition, a failure of the central visual field can be detected in the course of the visual field measurement (perimetry).Visual evoked potentials (VEP) are also recorded to assess the optic nerve. In the case of papillitis, this reveals a delayed nerve conduction velocity. Imaging techniques such as magnetic resonance imaging (MRI)or computed tomography (CT) are available for further diagnosis.
Complications
A variety of causative factors can be blamed for inflammation of the bundled optic nerves at their exit point from the eyeball, the optic disc. The exact cause of papillitis, as the nerve inflammation is called, is not always recognized. The main causes are infections and inflammation of nearby tissues, poisoning, allergies or autoimmune reactions of the immune system. Likewise, metabolic diseases such as diabetes mellitus can trigger papillitis. Complications that arise in the course of papillitis are central visual field loss, which can lead to blindness of the affected eye if the causative underlying disease is not treated. In cases where the underlying disease also heals without treatment, the complications of papillitis also resolve virtually by themselves without treatment. Special focus is placed on causative factors such as diabetes mellitus and autoimmune diseases that worsen if left untreated. For example, it is of tremendous importance that blood glucose levels are well controlled and managed in type 2 or type 1 diabetes to avoid papillitis and vessel wall damage to the arteries and arterioles. To avoid further complications, the course of autoimmune diseases is also important for targeted therapeutic interventions. For example, the degradation of the myelin sheaths of the bundled optic nerves by autoimmune disease is not reversible at an advanced stage, so that complete recovery of vision is not possible in this case.
When should you see a doctor?
Losses of vision are fundamentally worrisome. If they persist despite a period of recovery or a balanced night’s rest, a doctor should be consulted. In many cases, decreased vision can be triggered due to overwork or overexertion. In this case, after sufficient rest and relaxation, there is a complete regeneration of the usual visual acuity. In the event of an acute reduction in vision, a visit to the doctor should be made immediately. Reduced visual acuity as well as reduced perception of contours or colors should be presented to a physician. If a black or gray spot can be noticed in the field of vision, this is considered a sign of disease. If pain occurs as soon as the eyes are moved, a doctor should be consulted. Sensitivity to light stimuli or slight pressure on the eye should be investigated and treated. A doctor is also needed if there is a headache, an increased risk of falling or having an accident, or psychological irregularities. Characteristic of papillitis is an increase in symptoms as soon as sports activities are performed or the affected person is in an environment with an increased ambient temperature. A sudden inability to see in a sauna or hot baths should therefore be immediately presented to a doctor. If aggressive tendencies or weepiness are evident in behavior, clarification of the cause is needed.
Treatment and therapy
Treatment of papillitis is based on the trigger of the inflammatory process. Depending on the particular cause or underlying primary disease, neurologic or internal medicine adjunctive measures take place, for example. Drug therapy with anti-inflammatory corticosteroids (e.g. cortisone) accelerates the resolution of the inflammation and is often indispensable in the case of a severe inflammatory process to prevent long-term damage. However, for high-dose drug treatment with corticosteroids, other diseases such as tuberculosis, gastric ulcers, diabetes mellitus or hypertension must not be present. Anti-inflammatory drugs are administered orally, but can also be administered intravenously in high doses and for faster efficacy. Taking cortisone can result in side effects and is therefore not without risk, depending on the underlying disease. Side effects include weight gain, osteoporosis, water retention, and a weakened immune system. If infectious causes are identified as the trigger for papillitis, the relevant pathogens are treated with antibiotics or antivirals.In general, the chances of recovery are good if the causes and symptoms of the inflammation are treated quickly. However, if therapy is delayed, a longer-lasting inflammation, greater complications, and thus ultimately a poorer prognosis are to be expected.
Outlook and prognosis
Papillitis offers a relatively good prognosis. Vision often deteriorates insidiously, often as a result of infection, and becomes more severe within one to two weeks before the disease reaches its nadir. With early therapy, the inflammation of the optic nerve subsides within four to five weeks. However, many patients report persistent problems seeing colors and contrasts. In the atypical forms, severe visual complaints often remain. If papillitis is left untreated, loss of the optic nerve papilla may occur. If the optic nerve papilla disappears, vision also remains severely impaired. Thus, the prospect of recovery is only given with early treatment. Due to the poor vision, the patient’s quality of life is limited during the disease. Life expectancy, on the other hand, is not reduced. However, papillitis is often associated with multiple sclerosis, which usually takes a severe course and is accompanied by further health complications. The prognosis of papillitis is made by the ophthalmologist or a neurologist. In addition to the time of diagnosis, the prognosis is also based on the patient’s general condition and willingness to undergo various therapeutic procedures.
Prevention
Because the triggers of papillitis remain unexplained in most cases of disease, there is also no clearly identifiable, effective preventive measure. However, regular ophthalmologic checkups are recommended in cases of corresponding underlying diseases.
Follow-up care
In most cases of papillitis, only limited measures of direct aftercare are available to the affected person. For this reason, early diagnosis is very important in this disease so that further complications can be prevented. Self-healing of papillitis cannot occur, so that the affected person can completely lose vision if the disease is not treated in time. Most patients are dependent on taking various medications that can alleviate and limit the symptoms. The affected person should always pay attention to a correct dosage and also to a regular intake of the medication in order to alleviate the discomfort permanently and correctly. When taking antibiotics, it should also be noted that they must not be taken together with alcohol. Regular checks and examinations by a doctor are also very important and can prevent further complications. A direct prediction about the further course is usually not possible with papillitis, because it depends strongly on the time of diagnosis and the severity of the symptoms. In some cases, this disease also reduces the life expectancy of the affected person.
What you can do yourself
Papillitis is usually treated with the help of cortisone. The patient can support the cortisone therapy by consulting closely with the physician during therapy and informing him or her of any accompanying symptoms. Close monitoring is particularly important with high-dose cortisone administration, as there is an increased risk of side effects and interactions. In addition, the eyes should be protected. Direct sunlight should be avoided, as should contact with aggressive care products. Patients should ensure sufficient sleep and avoid stress. If necessary, the diet must also be changed temporarily. A light diet supports the immune system and helps to fight the causative pathogen. If the papillitis is due to an autoimmune disease, further changes must be made. The physician in charge will usually give the patient the necessary advice and can consult other specialists if necessary. If, despite all the measures taken, problems recur, the doctor must be informed. In the case of serious illnesses, all self-help measures should be discussed with the doctor beforehand. The use of alternative remedies is also best done in consultation with a specialist.
