Is peripheral vision loss seen in patients with optic neuritis?

Peripheral Vision Loss in Optic Neuritis

Peripheral vision loss is not the typical presentation of optic neuritis—central visual field defects, particularly central scotomas, are the characteristic finding, though a wide variety of visual field patterns can occur including diffuse loss and nerve fiber bundle defects. 1, 2

Characteristic Visual Field Patterns

The visual field defects in optic neuritis vary considerably:

• Central or centrocecal scotomas occur in only 8.3% of cases, despite being classically associated with optic neuritis 2
• Diffuse visual field loss is actually the most common pattern, present in 48.2% of affected eyes 2
• Altitudinal or nerve fiber bundle-type defects (which can affect peripheral vision) occur in 20.1% of cases 2
• Other varied defects account for 23.4% of presentations 2

Central scotomas and red-green color desaturation are the characteristic symptoms emphasized in diagnostic criteria, not peripheral field loss 1

Clinical Implications

The wide variety of visual field defects creates diagnostic challenges:

• The pattern of visual field loss has limited utility in distinguishing optic neuritis from other optic nerve disorders like ischemic optic neuropathy, precisely because the presentations are so variable 2
• Visual field defects, commonly central scotomas, remain a key diagnostic feature, but clinicians should not exclude optic neuritis based solely on the absence of central field involvement 1

Fellow Eye Involvement

An important clinical finding is that asymptomatic visual field defects in the fellow eye are common, occurring in 68.8% of patients at baseline 2. This subclinical involvement does not represent true bilateral disease but rather evidence of prior or concurrent demyelinating activity.

Red Flags for Atypical Presentations

When peripheral or unusual field defects occur with other concerning features, consider atypical etiologies:

• Bilateral simultaneous involvement suggests NMOSD or MOGAD rather than typical MS-related optic neuritis 3, 1
• Posterior optic nerve involvement extending to the chiasm indicates possible NMOSD 3, 1
• Evidence of chiasmal or retrochiasmal visual field defects was present in only 2.9% of optic neuritis patients, representing atypical presentations 2

Central scotomas may remain permanent despite treatment, but this represents residual central rather than peripheral dysfunction 4