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  • 1.  Is this a Nerve mass or Neuritis?... I put my penny on:

    Posted 07-25-2025 00:10

    Dear NeuroOphthalmologist GURUS

    -specially those NeuroRads present  ;)

    (See the videos attached)

    I would appreciate your expertise on a patient that is ALMOST already blind, Right eye... progressively since May.

    She is a 35 year-old female with previous hx of metastatic breast angiosarcoma 2021 RIGTH side s/p chemotherapy -radiation- mastectomy, 2023 LEFT breast recurrence/mets s/p chemo-mastectomy-then radiation that she finished April 2025

    -BEFORE finishing her radiation cycles she started noticing mild RIGHT VISION LOSS and progressed to eye pain

    5/1/25: NEUROOP eval 20/40 OD, inferior altitudinal defect questionable mild papillitis(?)

    -MRI showed a focal abnormal T2 hyper intense signal on intraorbital right optic nerve concerning for optic neuritis 

    -Tx solumedrol IV for 5 days AND DC with oral pred 60mg--> VA 20/30 OD and VF inferior altitudinal defect mild improved(not resolved).

    6/24/25: while tapering down oral prednisone...Worsened VA and VF and prednisone was increased to  60 mg 
    --However, on 7/1/25, VA: 20/400 and VF worsened. Pt received solumedrol 1 gram IV one day and IVIG. Nephrologist refused to do plasmapheresis

    -CSF cytology: Flow cytometry inconclusive due to limited CSF sample volume. CSF studies: negative for Aquaporin 4 antibody, ACE, oligoclonal bands, VDRL, West Nile Virus antibody, Lyme disease

    Serum studies: negative for Anti MOG cell based , Anti-Aquaporin cell based, normal Mylein basic protein level.

    I see the patient in in my hospital 7/16/25 already with ~VA 20/800 in supero nasal quadrant

    -CSF flow cytometry pending, but cancer mets is low in my DDx

    Per my review of the multiple MRIs since April, there is a focal mass/lesion, too delimited to be only neuritis, even since May, that has grown.

    -See the videos attached

    --I PUT MY PENNY ON... AVM or vascular tumor of the optic nerve vs vascularized ONS meningioma (but is growing too fast)

    How about you?

    PS.-If interested in chemo received: 2022 Chemotherapy (Gemcitabine, Docetaxel, ifosfamide, Doxorubicin); 2023-24 Chemotherapy (Adriamycin/Zinecard/ifosfamide) 

    Thank you for your expertise!
    Claudia Prospero Ponce 


  • 2.  RE: Is this a Nerve mass or Neuritis?... I put my penny on:

    Posted 07-25-2025 04:28
    From the story this is either metastasis of a paraneoplastic syndrome so , the radiologist may give his opinion about the nature of, also antibodies and calcium serum level may decide , but also you may get in an ocular oncologist to say wether biopsy would do any harm in her condition , some Tumors respond partially to large doses of steroids , so initial steroid response may be deceptive 



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  • 3.  RE: Is this a Nerve mass or Neuritis?... I put my penny on:

    Posted 07-25-2025 21:10

    Do you have a coronal T1-fat sat post-GAD? from the axial images it is difficult to tell if the lesion is within the nerve proper or of the nerve sheath. I did not appreciate any flow in the TOF sequence. As many AVMs are hemorrhagic especially when they become symptomatic, is there a hemorrhage sequence (GRE, SWI, etc)? If you are worried about an AVM, a conventional angiogram might be helpful.

    However, for a rapidly growing mass with progressive vision loss in a patient with cancer, I would be most concerned about metastases. Given the advanced vision loss, I would be in favor of biopsy for a few reasons: 1) to know what you are treating and can have better directed treatment in an effort to restore vision / prevent further vision loss; 2) confirming distant metastases would be important for management of the patient's cancer .

    Best,

    Drew



    ------------------------------
    Andrew Carey
    Associate Professor
    Wilmer Eye Institute, Johns Hopkins Medicine
    Baltimore MD
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    Original Message


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