Why did an optometrist find swollen optic nerves in the past, but a recent dilated eye exam by an ophthalmologist was normal, despite worsening symptoms of headaches, nasal spasms, and pressure in the head, face, and sinuses, and no relief from amitriptyline (generic name) and gabapentin (generic name), with normal MRI (Magnetic Resonance Imaging) and MRV (Magnetic Resonance Venography) scans?

Discordant Optic Nerve Findings: Understanding the Discrepancy

The most likely explanation for your discordant findings is that the initial optometrist observation may have represented transient optic disc changes that subsequently resolved, or alternatively, the ophthalmologist's examination may have missed subtle findings—particularly if performed without optimal dilation or if you have anatomic variants that can mimic swelling. 1

Why Optic Nerve Findings Can Differ Between Examiners

Technical and Timing Factors

• Examination technique matters significantly: Stereoscopic slit-lamp biomicroscopy through a dilated pupil (the gold standard) provides superior visualization compared to direct ophthalmoscopy, which many optometrists use 2
• Transient optic disc swelling can resolve: If you had true papilledema from elevated intracranial pressure that subsequently normalized, the disc appearance would improve—though your normal MRI and MRV make this less likely 3
• Inter-observer variability is substantial: Studies show poor agreement between examiners when assessing optic disc abnormalities, particularly when comparing direct ophthalmoscopy to more sophisticated techniques 2

Diagnostic Pitfalls Leading to Discordant Findings

• Pseudopapilledema from optic disc drusen is the most common cause of falsely diagnosing optic nerve swelling, occurring in up to 2% of the population and often appearing as disc elevation without true edema 1
• Overdiagnosis of optic nerve abnormalities occurs in approximately 60% of referrals, with the most common error being overreliance on a single examination finding without considering alternative explanations 4
• Small, crowded optic discs (hyperopic eyes) can appear elevated and mimic swelling even when completely normal 1

Critical Red Flags You Should Investigate

Your Worsening Symptoms Demand Specific Evaluation

Given your progressive symptoms (headaches, nasal spasms, facial/sinus pressure) despite normal neuroimaging, you need targeted evaluation for conditions that can cause optic nerve changes with normal MRI/MRV:

• Bilateral optic neuritis from autoimmune causes (NMOSD, MOG-antibody disease) can present with normal brain MRI but requires urgent serologic testing for AQP4-IgG and MOG-IgG antibodies 5
• These conditions have devastating consequences if missed: NMOSD causes severe vision loss with poor recovery and requires aggressive immunosuppression to prevent relapses 5
• Red flags for atypical optic neuritis include bilateral involvement, severe vision loss, prominent disc edema, and posterior optic nerve involvement extending to the chiasm 5

Specific Testing You Need Now

Request the following from your ophthalmologist or neuro-ophthalmologist:

• Optical coherence tomography (OCT) of the optic nerves: This provides objective, quantitative measurement of retinal nerve fiber layer thickness and can detect subtle changes missed on clinical examination 2
• Orbital MRI with fat-suppressed sequences and contrast: Standard brain MRI may miss isolated optic nerve pathology; dedicated orbital imaging with coronal fat-suppressed T2-weighted sequences optimally visualizes optic nerve lesions 5, 6
• Serum antibody testing for AQP4-IgG and MOG-IgG: These tests differentiate between multiple sclerosis, NMOSD, and MOG-antibody disease, which require completely different treatment approaches 5
• Visual evoked potentials (VEP): Bilateral demyelination on VEP is a red flag for atypical optic neuritis even with normal ophthalmoscopy 5

Why Your Medications Failed

Amitriptyline and Gabapentin Target Different Pathophysiology

• These medications treat neuropathic pain and migraine, not inflammatory or structural optic nerve disease 5
• If you have inflammatory optic neuritis (particularly NMOSD or MOG-antibody disease), you need corticosteroids acutely and maintenance immunosuppression, not neuropathic pain medications 5
• Treatment delay beyond 2 weeks is an unfavorable prognostic factor for optic neuritis, making urgent diagnosis critical 5

What You Must Do Next

Insist on referral to a neuro-ophthalmologist (not a general ophthalmologist) who can perform:

1. Detailed stereoscopic examination of both optic nerves through dilated pupils using slit-lamp biomicroscopy 2, 1
2. OCT imaging to objectively quantify retinal nerve fiber layer thickness 2
3. Dedicated orbital MRI with fat suppression and contrast, not just brain MRI 5
4. Serologic testing for AQP4-IgG and MOG-IgG if any concern for inflammatory optic neuropathy 5

The combination of worsening symptoms, prior optic nerve findings, and failure of empiric medications suggests you need definitive diagnosis rather than symptomatic treatment. 1, 4 Your normal brain MRI/MRV does not exclude serious optic nerve pathology, particularly inflammatory conditions that require urgent, specific treatment to prevent permanent vision loss 5.