What is Papillitis? What are the symptoms of papillitis? Are these symptoms temporary, or are they lasting for life?  How can we identify it?  Let's explore all these in this article

Introduction

Papillitis is the inflammation of the optic nerve head, typically caused by nearby inflammation in the retina. The optic disc becomes swollen, and its edges look blurry. It commonly affects only one eye. When both eyes are affected, we can differentiate papilledema from papillitis, as papillitis typically causes reduced vision.¹

Symptoms and their importance

 There are various symptoms of Papillitis, including vision loss, eye pain, and problems distinguishing colours correctly. It's also called dyschromatopsia.

Many people with paillitis lose vision in only one eye, in almost 70%of cases. That is one of the signs that the condition has worsened. The levels of vision loss can vary, as some individuals experience very mild symptoms, while others lose the ability to see light or colours. 

In some cases, vision improves on its own, while in others, permanent vision loss occurs if the cause is not identified and treated. Papillitis can occur without warning, following a viral infection or a medical condition.²

Early detection and intervention can help manage the condition and prevent further complications.

Understanding papillitis

Importance of the optic nerve

A healthy optic nerve is crucial as it carries signals from the eye to the brain. These signals are initiated in the retina when light hits it. The photoreceptors present in the retina create electric signals. These signals are modified by other retinal cells and are transmitted through the optic nerve to the brain. 

When there is damage to the optical nerve or retinal nerve fibre, the signals do not transmit properly. There are many things that cause optic nerve damage, like infections, injuries, poor blood flow, cancer spread, toxins, or due to a lack of nutrients.³

Causes of papillitis

Papillitis, also known as optic neuritis, typically involves swelling of the optic nerve due to nerve damage and is categorized as a type of optic neuropathy. When it affects both eyes, the primary symptom is vision loss, in contrast to papilledema, which initially causes normal vision.⁴

The most common causes are demyelinating optic neuritis, NMOSD, Anti- MOG optic neuritis.

Many other possible causes include viral infections, Toxoplasmosis, Cat Scratch disease, Sarcoidosis, Syphilis, Systemic lupus erythematosus(SLE), and Lyme disease.

Key symptoms of papillitis

Clinical features of Papillitis are similar to those of optic neuritis.⁴ There is a sudden loss of vision in one eye, and sometimes both eyes can be affected. The severity of vision loss can be mild to complete blindness in the affected eye. Eye pain can be an early symptom and is often noticed before vision problems occur. In addition, people affected might also notice that colours have faded, become less vibrant, and have trouble with contrast.

Physical evaluation of papillitis symptoms

Relative Afferent Pupillary Defect (RAPD). It is also known as the Marcus Gunn Phenomenon (RAPD).¹⁰ It is used to describe abnormal reactions of he pupil in specific eye conditions. In a normal condition, when bright light is shone into the eye, the pupil becomes smaller, but in Relative afferent pupillary defect, it's the opposite. The affected eye gets bigger instead of smaller.   It is a non-invasive test used to detect retinal or optic nerve dysfunction.⁹

• Vision acuity- vision in the affected eyes is reduced from slight blurriness to complete vision loss, depending on how severe the inflammation is Fundoscopic exam- in papillitis, the optic disc appears swollen and red; this is usually seen in children, but not in every case
• Visual field defects- tests often reveal blind spots in central vision where the optic nerve is damaged
• Colour vision testing- individuals have trouble differentiating colours
• Contrast sensitivity- it might be difficult to differentiate between light and dark shades, especially subtle grays³

Diagnosis of papillitis

Doctors will use an MRI to evaluate the brain and eye area if results show inflammation in the optic nerve. The MRI helps the doctors get a clear picture of what's happening inside the brain and optic nerve so they can make the right diagnosis and choose the best treatment.

Additional tests

• Blood test for autoimmune disease- It is mainly important in case the symptoms are unusual, there is a loss of vision that has happened more than once, and when both eyes are involved
• Infection screening- It is done as some infections, like syphilis, Lyme disease, and Tuberculosis, can also cause optic nerve inflammation, and treatment may differ
• Spinal Tap (CSF Analysis)- It is done for any sign of multiple sclerosis(MS)
• Visual Evoked Potential (VEP)Test- It is used to check how quickly the brain responds to visual signals. When there is a delay, it suggests there is damage or slowing in the optic nerve³

Management and treatment

Depending on the severity, various steroid treatments are used to manage Papillitis, such as corticosteroids, which are used to reduce inflammation and manage symptoms. Intravenous steroids are used on a case-by-case basis; the steroid is often the go-to treatment for severe cases. Steroids help speed up vision recovery, often addressing the root cause of the inflammation. Often, immunosuppressants, such as rituximab and azathioprine, are used when an individual with papillitis has an autoimmune condition, like NMOSD or Lupus. Immunosuppressants help to prevent the condition from reactivating. 

When steroids do not give results in severe cases, then Plasma exchange(PLEX) is used.¹¹ This helps to remove the harmful antibodies and calm the immune response.³ Follow-up and monitoring are essential after visual recovery and the potential side effects of steroids. For mild to moderate pain, analgesics and NSAIDs can be used.

Complications and long-term effects

There are risks associated with delayed treatment, including lasting damage to the optic nerve, blurry vision, blind spots, or loss of side vision. 3-5% of patients do not fully recover because of recurring episodes and underlying systemic conditions. Although steroid treatment would help in recovery, it can cause many side effects. If there is permanent damage to the optic nerve, it might shrink and lead to optic atrophy. These physical changes impact the quality of everyday life

FAQ’s

What is multiple sclerosis?

It is a common condition affecting the brain and spinal cord. The body's immune system attacks the nervous system, leading to physical or mental difficulties

Is there any other name for the optic disc?

 Yes, the other name commonly used for the optic disc is the optic nerve head

What is Optical Coherence Tomography(OCT)?

It is an eye scan procedure that shows  detailed images of the optic nerve and retina 

What are the blood tests for autoimmune diseases?

Antinuclear antibody(ANA), Aquaporin-4antibodies (Anti-AQP4), MOG-IgG antibodies

What can be expected when there are side effects from steroids?

There is a high level of glucose in our body, blood pressure might be elevated, and Immunity would be compromised, leading to recurrent infections

Summary

Papillitis is an inflammation of the optic nerve head, which is caused by inflammation in the retina. When this happens, the optic disc becomes swollen, and vision becomes blurry, accompanied by eye pain. Slowly, the condition worsens. Although papillitis usually affects one eye, it is not uncommon for both eyes to be affected by the condition.

Early detection allows for faster treatment, and identifying the severity helps doctors determine the proper treatment options, such as which medication, i.e, steroids, is suitable for specific cases. Monitoring the symptoms of steroids and follow-up treatments is essential to assess recovery and to prevent relapse.