Current Treatment Options in Neurology

, Volume 3, Issue 4, pp 389–398 | Cite as

Optic neuritis

  • Laura J. Balcer
Article

Opinion statement

Patients with signs and symptoms consistent with acute monosymptomatic optic neuritis should undergo evaluation with gadolinium-enhanced MRI of the brain and orbits to determine whether or not they are at high risk for the development of clinically definite multiple sclerosis (CDMS). The presence of two or more white matter lesions (3 mm or larger in diameter, at least one lesion periventricular or ovoid) suggests high risk for CDMS, and should prompt immediate treatment as follows:
  • Intravenous methylprednisolone sodium succinate (1 g intravenously [IV] per day for 3 days) followed by oral prednisone (1 mg/kg per day for 11 days) with a 4-day taper (20 mg on day 1, 10 mg on days 2 and 4).

  • Interferon beta 1-a, which has been demonstrated to significantly reduce the 3-year probability of the development of CDMS and the development of clinically silent MRI lesions in high-risk patients with acute optic neuritis, should be considered following IV methylprednisolone treatment (30 mg intramuscularly [IM] weekly).

In monosymptomatic patients with fewer than two white matter lesions by MRI, and in patients for whom a diagnosis of CDMS has been established, treatment with IV methylprednisolone followed by oral prednisone (as outlined), should be considered on an individual basis and may hasten visual recovery, but has not been demonstrated to affect long-term visual outcome. In all cases of typical acute monosymptomatic demyelinating optic neuritis, oral prednisone alone at a dose of 1 mg/kg per day, without prior treatment with IV methylprednisolone (1 g per day for 3 days), may increase the risk for recurrent optic neuritis, and should be avoided.

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References and Recommended Reading

  1. 1.
    Beck RW: The Optic Neuritis Treatment Trial. Arch Ophthalmol 1988, 106:1051–1053.PubMedGoogle Scholar
  2. 2.
    Optic Neuritis Study Group: The clinical profile of acute optic neuritis: experience of the Optic Neuritis Treatment Trial. Arch Ophthalmol 1991, 109:1673–1678.Google Scholar
  3. 3.
    Beck RW, Cleary PA, Anderson MA, et al.: A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. N Engl J Med 1992, 326:581–588.PubMedCrossRefGoogle Scholar
  4. 4.
    Liu GT: Visual loss: optic neuropathies. In: In Neuro-Ophthalmology: Diagnosis and Management. Edited by Liu GT, Volpe NJ, Galetta SL. Philadelphia: WB Saunders; 2000:103–187.Google Scholar
  5. 5.
    Kaufman DI, Trobe JD, Eggenberger ER, Whitaker JN: Practice parameter: the role of corticosteroids in the management of acute monosymptomatic optic neuritis. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000, 54:2039–2044. This Practice Parameter presents a review and classification of literature regarding the use of corticosteroids for the treatment of acute monosymptomatic optic neuritis. The authors outline recommendations for treatment, and conclude that although high-dose IV methylprednisolone may hasten the speed of visual recovery, there is no evidence of long-term benefit for visual function.PubMedGoogle Scholar
  6. 6.
    Percy AK, Nobrega FT, Kurland LT: Optic neuritis and multiple sclerosis: an epidemiologic study. Arch Ophthalmol 1972, 87:135–139.PubMedGoogle Scholar
  7. 7.
    Rizzo JF, Lessell S: Risk of developing multiple sclerosis after uncomplicated optic neuritis. A long-term prospective study. Neurology 1988, 38:185–190.PubMedGoogle Scholar
  8. 8.
    Beck RW, Cleary PA, Trobe JD, et al.: The effect of corticosteroids for acute optic neuritis on the subsequent development of multiple sclerosis. N Engl J Med 1993, 329:1764–1769.PubMedCrossRefGoogle Scholar
  9. 9.
    Optic Neuritis Study Group: The five-year risk of multiple sclerosis after optic neuritis: experience of the Optic Neuritis Treatment Trial. Neurology 1997, 49:1404–1413. In a 5-year follow-up of the Optic Neuritis Treatment Trial cohort, the Optic Neuritis Study Group found the cumulative probability of CDMS to be 30%. This risk was similar across treatment groups. However, baseline MRI was a powerful predictor of CDMS risk at 5 years: 51% for patients with three or more white matter lesions, 37% for one to two matter lesions, 16% for no lesions.Google Scholar
  10. 10.
    Beck RW, Optic Neuritis Study Group: The Optic Neuritis Treatment Trial: implications for clinical practice. Arch Ophthalmol 1992, 110:331–332.PubMedGoogle Scholar
  11. 11.
    Jacobs LD, Beck RW, Simon JH, et al.: Intramuscular interferon beta-1a therapy initiated during a first demyelinating event in multiple sclerosis. N Engl J Med 2000, 343:898–904. This randomized trial of 383 patients compared the effects of interferon beta-1a vs placebo on the subsequent development of clinically definite MS following a first demyelinating event. Participants had brain MRI findings consistent with high risk for CDMS as established by the ONTT (two or more white matter lesions, greater than or equal to 3 mm in diameter, at least one lesion periventricular or ovoid). This study demonstrated efficacy for interferon beta-1a not only in reducing the 3-year cumulative probability of CDMS, but also showed that treated patients had a reduced rate of accumulation of new but clinically silent lesions on brain MRI.PubMedCrossRefGoogle Scholar
  12. 12.
    Wakakura M, Mashimo K, Oono S, et al.: Multicenter clinical trial for evaluating methylprednisolone pulse treatment of idiopathic optic neuritis in Japan. Jpn J Ophthalmol 1999, 43:133–138.PubMedCrossRefGoogle Scholar
  13. 13.
    Wakakura M, Minei-Higa R, Oono S, et al.: Baseline features of idiopathic optic neuritis as determined by a multicenter treatment trial in Japan. Jpn J Ophthalmol 1999, 43:127–132.PubMedCrossRefGoogle Scholar
  14. 14.
    Beck RW, Optic Neuritis Study Group: Corticosteroid treatment of optic neuritis: a need to change treatment practices. Neurology 1992, 42:1133–1135.PubMedGoogle Scholar
  15. 15.
    Beck RW, Kupersmith MJ, Cleary PA, et al.: Fellow eye abnormalities in acute unilateral optic neuritis: experience of the Optic Neuritis Treatment Trial. Ophthalmology 1993, 100:691–698.PubMedGoogle Scholar
  16. 16.
    Beck RW, Arrington J, Murtagh FR, et al.: Brain MRI in acute optic neuritis: experience of the Optic Neuritis Study Group. Arch Neurol 1993, 8:841–846.Google Scholar
  17. 17.
    Beck RW, Cleary PA, Optic Neuritis Study Group: Optic Neuritis Treatment Trial: one-year follow-up results. Arch Ophthalmol 1993, 111:773–775.PubMedGoogle Scholar
  18. 18.
    Keltner JL, Johnson CA, Spurr JO, et al.: Baseline visual field profile of optic neuritis: the experience of the Optic Neuritis Treatment Trial. Arch Ophthalmol 1993, 111:231–234.PubMedGoogle Scholar
  19. 19.
    Beck RW, Cleary PA, Backlund J, et al.: The course of visual recovery after optic neuritis: experience of the Optic Neuritis Treatment Trial. Ophthalmology 1994, 101:1771–1178.PubMedGoogle Scholar
  20. 20.
    Trobe JD, Beck RW, Moke PS, Cleary PA: Contrast sensitivity and other vision tests in the Optic Neuritis Treatment Trial. Am J Ophthalmol 1996, 121:547–553.PubMedGoogle Scholar
  21. 21.
    The Optic Neuritis Study Group: Visual function 5 years after optic neuritis: experience of the Optic Neuritis Treatment Trial. Arch Ophthalmol 1997, 115:1545–1552. Visual outcome data from the Optic Neuritis Treatment Trial cohort at 5 years demonstrated no significant differences in visual function test scores across treatment groups. However, the cumulative probability of recurrent optic neuritis in either eye remained significantly higher in the oral prednisone group (41%) compared with the IV methylprednisolone and placebo groups (25% for both groups).Google Scholar
  22. 22.
    Keltner JL, Johnson CA, Spurr JO, Beck RW: Comparison of central and peripheral visual field properties in the Optic Neuritis Treatment Trial. Am J Ophthalmol 1999, 128:543–553.PubMedCrossRefGoogle Scholar
  23. 23.
    Fang JP, Donahue SP, Lin RH: Global visual field involvement in acute unilateral optic neuritis. Am J Ophthalmol 1999, 128:554–565.PubMedCrossRefGoogle Scholar
  24. 24.
    Fang JP, Lin RH, Donahue SP: Recovery of visual field function in the Optic Neuritis Treatment Trial. Am J Ophthalmol 1999, 128:566–572.PubMedCrossRefGoogle Scholar
  25. 25.
    Arnold AC: Visual field defects in the Optic Neuritis Treatment Trial: central vs. peripheral, focal vs. global. Am J Ophthalmol 1999, 128:632–634.PubMedCrossRefGoogle Scholar
  26. 26.
    Cleary PA, Beck RW, Bourque LB, et al.: Visual symptoms after optic neuritis: results from the Optic Neuritis Treatment Trial. J Neuro-Ophthalmol 1997, 17:18–28.CrossRefGoogle Scholar
  27. 27.
    Cole SR, Beck RW, Moke PS, et al.: The National Eye Institute Visual Function Questionnaire: experience of the ONTT. Invest Ophthalmol Vis Sci 2000, 41:1017–1021.PubMedGoogle Scholar
  28. 28.
    Trobe JD, Sieving PC, Guire KE, Fendrick AM: The impact of the Optic Neuritis Treatment Trial on the practices of ophthalmologists and neurologists. Ophthalmology 1999, 106:2047–2053. Random samples of 900 neurologists and 987 ophthalmologists received a mail survey to evaluate whether practice patterns have been affected by results of the ONTT, and how specific recommendations have been interpreted. Ninety-five percent of neurologists and 90% of ophthalmologists reported reductions in their use of oral prednisone (suggesting correct interpretation of ONTT results). However, high percentages of respondents in both groups (38% of ophthalmologists, 59% of neurologists) reported using IV methylprednisolone for ‘improving 1-year visual outcome’ (illustrating that trial recommendations may be embraced without a complete understanding of results).PubMedCrossRefGoogle Scholar
  29. 29.
    Balcer LJ, Baier ML, Pelak VS, et al.: New low-contrast vision charts: reliability and test characteristics in patients with multiple sclerosis. Multiple Sclerosis 2000, 6:163–171.PubMedGoogle Scholar
  30. 30.
    Jacobs LD, Cookfair D, Rudick RA, et al.: Intramuscular interferon beta-1a for disease progression in relapsing multiple sclerosis. Ann Neurol 1996, 39:285–294.PubMedCrossRefGoogle Scholar
  31. 31.
    Söderström M, Ya-Ping J, Hillert J, Link H: Optic neuritis: prognosis for multiple sclerosis from MRI, CSF, and HLA findings. Neurology 1998, 50:708–714.PubMedGoogle Scholar
  32. 32.
    Chrousos GA, Kattah JC, Beck RW, et al.: Side effects of glucocorticoid treatment: experience of the Optic Neuritis Treatment Trial. JAMA 1993, 269:2110–2112.PubMedCrossRefGoogle Scholar
  33. 33.
    Drug Topics Red Book. Montvale, NJ: Medical Economics Co., Inc.; 2000.Google Scholar
  34. 34.
    Physicians Desk Reference. Montvale, NJ: Medical Economics Co., Inc.; 2001.Google Scholar
  35. 35.
    Trauzettel-Klosinski S, Axmann D, Diener HG: The Tübingen Study on optic neuritis treatment: a prospective, randomized and controlled trial. Clin Vis Sci 1993, 8:385–394.Google Scholar
  36. 36.
    Sellebjerg F, Nielsen HS, Frederiksen JL, et al.: A randomized, controlled trial of oral high-dose methylprednisolone in acute optic neuritis. Neurology 1999, 52:1479–1484.PubMedGoogle Scholar
  37. 37.
    Kendrick M, Johnson KI: Long-term treatment of multiple sclerosis with interferon beta may be cost effective. Pharmacoeconomics 2000, 18:45–53.PubMedCrossRefGoogle Scholar
  38. 38.
    van Engelen BGM, Hommes OR, Pinkers A, et al.: Improved vision after intravenous immunoglobulin in stable demyelinating optic neuritis [letter]. Ann Neurol 1992, 32:834–835.PubMedCrossRefGoogle Scholar
  39. 39.
    Raine CS, Hintzen R, Traugott U, et al.: Oligodendrocyte proliferation and enhanced CNS remyelination after therapeutic manipulation of chronic relapsing EAE. Ann NY Acad Sci 1988, 540:712–714.PubMedCrossRefGoogle Scholar
  40. 40.
    van Engelen BGM, Miller DJ, Pavelko KD, et al.: Promotion of remyelination by polyclonal immunoglobulin and IVIg in Theiler’s virus induced demyelination and in MS. J Neurol Neurosurg Psychiatry 1994, 57(suppl):65–68.PubMedCrossRefGoogle Scholar
  41. 41.
    Brady KM, Brar AS, Lee AG, et al.: Optic neuritis in children: clinical features and visual outcome. J AAPOS 1999, 3:98–103.PubMedCrossRefGoogle Scholar
  42. 42.
    Lucchinetti CF, Kiers L, O’Duffy A, et al.: Risk factors for developing multiple sclerosis after childhood optic neuritis. Neurology 1997, 49:1413–1418.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2001

Authors and Affiliations

  • Laura J. Balcer
    • 1
  1. 1.Division of Neuro-ophthalmology, Department of Neurology and OphthalmologyUniversity of Pennsylvania School of MedicinePhiladelphiaUSA

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