The swollen optic nerve: an approach to diagnosis and management

The differential diagnosis of swollen optic nerves differs according to whether the swelling is unilateral or bilateral, or whether visual function is normal or affected. Patients with a unilaterally swollen optic nerve and normal visual function most likely have optic nerve head drusen. Patients with abnormal visual function most likely have demyelinating optic neuritis or non-arteritic anterior ischaemic optic neuropathy. Patients with bilaterally swollen optic nerve heads and normal visual function most likely have papilloedema, and require neuroimaging followed by lumbar puncture. However, if their visual function is affected, the most likely causes are bilateral demyelinating optic neuritis, neuromyelitis optica spectrum disorder and anti-myelin oligodendrocyte glycoprotein optic neuritis: these patients require investigating with contrast-enhanced MRI of the orbits.