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Acute Optic Neuropathy in Older Adults: Differentiating Between MOGAD Optic Neuritis and Nonarteritic Anterior
Nanthaya Tisavipat1, Hadas Stiebel-Kalish1, Dahlia Palevski1
1From the Department of Neurology (N.T., D.A.T., S.J.P., E.P.F., J.J.C.); Center for MS and Autoimmune Neurology (N.T., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Neuro-Ophthalmology Division (H.S.-K., D.P., O.Y.B.), Department of Ophthalmology, Rabin Medical Center and Faculty of Medicine; Felsenstein Medical Research Center (H.S.-K.), Tel Aviv University, Israel; Department of Neurology and Neurological Sciences (H.E.M.); Department of Ophthalmology (H.E.M., P.C.), Stanford University, Palo Alto, CA; Department of Ophthalmology (P.C.), Rajavithi Hospital; Department of Ophthalmology (T.P.), Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Department of Neurology (A.D.H., E.S.S.), Johns Hopkins University; Department of Ophthalmology (A.D.H., S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; George Washington University School of Medicine and Health Sciences (A.-R.S.), Washington, DC; Department of Ophthalmology (D.A.T., K.D.C., J.J.C.); and Department of Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN.
Background And Objectives:
Myelin oligodendrocyte glycoprotein antibody-associated disease optic neuritis (MOGAD-ON) and nonarteritic anterior ischemic optic neuropathy (NAION) can cause acute optic neuropathy in older adults but have different managements. We aimed to determine differentiating factors between MOGAD-ON and NAION and the frequency of serum MOG-IgG false positivity among patients with NAION.
Methods:
In this international, multicenter, case-control study at tertiary neuro-ophthalmology centers, patients with MOGAD presenting with unilateral optic neuritis as their first attack at age 45 years or older and age-matched and sex-matched patients with NAION were included. Comorbidities, clinical presentations, acute optic disc findings, optical coherence tomography (OCT) findings, and outcomes were compared between MOGAD-ON and NAION. Multivariate analysis was performed to find statistically significant predictors of MOGAD-ON. A separate review of consecutive NAION patients seen at Mayo Clinic, Rochester, from 2018 to 2022, was conducted to estimate the frequency of false-positive MOG-IgG in this population.
Results:
Sixty-four patients with unilateral MOGAD-ON were compared with 64 patients with NAION. Among patients with MOGAD-ON, the median age at onset was 56 (interquartile range [IQR] 50-61) years, 70% were female, and 78% were White. Multivariate analysis showed that eye pain was strongly associated with MOGAD-ON (OR 32.905; 95% CI 2.299-473.181), while crowded optic disc (OR 0.033; 95% CI 0.002-0.492) and altitudinal visual field defect (OR 0.028; 95% CI 0.002-0.521) were strongly associated with NAION. On OCT, peripapillary retinal nerve fiber layer (pRNFL) thickness in unilateral MOGAD-ON was lower than in NAION (median 114 vs 201 μm, p < 0.001; median pRNFL thickening 25 vs 102 μm, p < 0.001). MOGAD-ON had more severe vision loss at nadir (median logMAR 1.0 vs 0.3, p < 0.001), but better recovery (median logMAR 0.1 vs 0.3, p = 0.002). In the cohort of consecutive NAION patients, 66/212 (31%) patients with NAION were tested for MOG-IgG and 8% (95% CI 1%-14%) of those had false-positive serum MOG-IgG at low titers.
Discussion:
Acute unilateral optic neuropathy with optic disc edema in older adults can be caused by either MOGAD-ON or NAION. Detailed history, the degree of pRNFL swelling on OCT, and visual outcomes can help differentiate the entities and prevent indiscriminate serum MOG-IgG testing in all patients with acute optic neuropathy.
