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Uveitis and hyperintense optic nerve on MRI FLAIR

  • 1.  Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 06-11-2026 03:41
    Edited by Michel Van Lint 06-11-2026 03:45
    47 year-old man, Caucasian
    Presents in 2023 with an idiopathic hypertensive, granulomatous anterior uveitis of the left eye only.
    There is an incomplete response to first local and later systemic immunosuppressive therapy.
    A recent MRI now reveals a hyperintense left optic nerve.
    Antibodies against NMO and MOG, as well as cervical MRI are negative.
    Currently, he still has a visual acuity of 1.0 and continues to have a chronic, low-grade unilateral anterior uveitis.
    No apparent RAPD, nor pain on eye movement.
    I asked for MRI with contrast, but got one without.
    The neurologist says he finds no arguments for a neuroinflammatory disorder and lumbar puncture was not deemed necessary.
    Would you agree with that or what do you think this could be? Neurosarcoidosis, SLE, GPA, ... ?
    Thank you,
    Michel
    PS. The arrow in the second image was put there by radiology. I suppose that tells how they think of me :)
    I am not convinced the prechiasmatic part of the right optic nerve looks normal.
    image
    image
    image


  • 2.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 06-11-2026 05:08
    Definitely I would oligoclobal band in CSF and all basic immunology , this could be one of the probabilities that you just mentioned , Also any history of viral illness , last week I had a case like that with HZO , though skin manifestation made diagnosis easy for the Uveitis and optic neuritis , but also I had some cases like that following a suspected FLU LiKE illness with all investigation negative 





  • 3.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 06-11-2026 07:32

    Thank you very much, I actually had not considered a viral infection. It will be useful to repeat the MRI scan later to see if there is any change. The LP was denied, but I will ask if there is room to reconsider.


    Original Message


  • 4.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 06-11-2026 07:41

    The Emory group had a recent excellent publication on T2 hyperintensity:

    Labella Álvarez F, Mosleh R, Bouthour W, Saindane AM, Bruce BB, Dattilo M, Newman NJ, Biousse V. Optic Nerve MRI T2-Hyperintensity: A Nonspecific Marker of Optic Nerve Damage. J Neuroophthalmol. 2024 Mar 1;44(1):22-29. doi: 10.1097/WNO.0000000000002017. Epub 2023 Nov 21. PMID: 38251954.

    Presumably infections like syphilis TB, and Lyme were already ruled out, Bartonella can cause a panuveitis. Has chest imaging been performed to look for sarcoid or other granulomatous disease?

    A fluorescein angiogram if not done can be useful to better characterize the uveitis.

    Viral uveitis is usually not granulomatous but if the patient does not respond as expected it is important to expand the differential and it is possible an incomplete response indicates a second etiology, perhaps viral infection in the setting of immunosuppression.

    In addition to LP, an AC tap for viral PCR maybe helpful.

    Best, 

    Drew



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

    Original Message


  • 5.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 06-11-2026 15:02
    I do not understand how, unless you were talking of just a "spillover papillopathy" from uveitis, that an LP would not be called for in concomitant granulomatous uveitis and optic neuritis.

    As an example, a lymphocytic pleocytosis might serve as a clue to neurosarcoid that would otherwise be missed.

    If they will not permit an LP, or if they do and it is equivocal, a PET CT of the whole body might both elucidate a revealing pattern of inflammation and/or yield a potential biopsy site.





  • 6.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 06-12-2026 09:34
    Edited by Michel Van Lint 06-12-2026 09:34

    Many thanks everyone for your answers.

    Infectious disease has been screened for.

    PET-CT was done in May last year and came back negative.

    Anterior chamber tap with PCR was performed early in the disease course in 2023 and was negative for herpes. He was also given a trial with aciclovir during follow-up, but to no avail.

    Fluorescein angiography has been done as well, but niot recently. I will schedule one.

    Next week, I will bring up this case with another colleague from neurology and discuss the LP, as this would be really welcome

    Also, although not mentioned by the radiologist, it appears that the prechiasmal right optic nerve is affected as well on MRI, but I may be mistaken.

    Thank you, much appreciated

    Michel


    Original Message


  • 7.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 06-13-2026 04:08
    Granulomatous uveitis with optic neuropathy is highly suggestive of sarcoid though ancillary testing (PET-CT etc may be negative).

    The only revealing signs may be exclusively venous (usually non-occlusive) vasculitis on FFA and granulomas on ICG.
    Worth also requesting serum Il-2R levels (much more sensitive than ACE) if not done already.

    If doing an LP could check for high CD4/8 ratio and Il-6 levels (non-specific markers of neurosarcoid)

    Best Wishes,

    Ajay 

    Ajay Patil MA (Cantab), MBBS, FRCOphth
    Consultant in Neuro-Ophthalmology & Inflammatory Eye Disease




    Original Message


  • 8.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 25 days ago
    Edited by Michel Van Lint 25 days ago

    Dear Ajay,

    Many thanks. Tomorrow he will have his lumbar puncture, along with orbital MRI with contrast.

    Today he had a pattern VEP, which was (affected left eye) delayed (130-140 ms) and also showed a decreased amplitude (2-3 µV).

    Looking back and checking the ganglion cell layer, I can recognise deficits in his GCL back in 2024.

    Nobody ever gave a second thought about the optic nerves, because he presented as an anterior uveitis, has visual acuity 1.0 and no pain on eye movement...

    Michel


    Original Message


  • 9.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 25 days ago
    Dear Colleagues,
    I would like to refer you to a report of 5 patients which was published in 1985. All of our patients were female, one had multiple sclerosis and four had probable multiple sclerosis. All had lardaceous keratic precipitates, some with posterior synechiae.  Three had Koeppe-like nodules at the pupillary margin, which resolved with topical prednisolone acetate 1% drops, only to recur when the drops were stopped.
    Kind regards,
    David M. Bachman, M.D.

    "Granulomatous Uveitis in neurological diseases." Bachman, DM,  Rosenthal, AR,  Beckingsale, AB,
    British Journal of Ophthalmology, 1985, 69, 192-196.



    Original Message


  • 10.  RE: Uveitis and hyperintense optic nerve on MRI FLAIR

    Posted 25 days ago

    Thank you, we did the first MRI scan to rule out MS, but there were no signs of demyelination


    Original Message


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