Management of optic neuritis in Ireland: a survey comparing the management practices of acute demyelinating optic neuritis amongst ophthalmologists and neurologists in Ireland

Abstract

Background

Acute optic neuritis (ON) is often the first manifestation of multiple sclerosis which is particularly common in Ireland. Despite the specific clinical details regarding investigations and management of ON provided by the Optic Neuritis Treatment Trial (ONTT), international surveys have shown that there are still notable differences in the management of ON between neurologists and ophthalmologists.

Aim

To compare the investigation and treatment of acute optic neuritis between ophthalmologists and neurologists in Ireland

Method

A survey consisting of a case scenario and questions regarding treatment and investigations of a patient with ON was emailed to ophthalmology consultants, trainees and medical ophthalmologists registered with the Irish College of Ophthalmologists and to neurology consultants and registrars registered with the Irish Institute of Clinical Neuroscience.

Results

One hundred sixty recipients responded out of 350 (46%). The majority of the neurologists would initiate steroid treatment regardless of the patient’s vision (75%), treat with 1 g IV methylprednisolone (100%) for 5 days (57%), perform an MRI brain and orbits with contrast (92%) and multiple laboratory tests (96%). In contrast, the ophthalmologists tended to initiate treatment depending on the patient’s vision (48%), treat with 1 g IV methylprednisolone (97%) for 3 days instead of 5 days (93%), perform MRI brain and orbits with contrast (73%) and favour electrophysiology testing (73%) over laboratory testing (68%).

Conclusions

Overall, most respondents would follow the ONTT guidelines regarding IV methylprednisolone. There was a significant difference in responses between the ophthalmologists and neurologists regarding who to treat, duration of treatment and appropriate investigations.

Appendix

Questionnaire

A 25 year old Irish Caucasian female presents with acute unilateral loss of vision with pain on eye movements. She has no previous ophthalmic history or medical history and is on no medication. You make the diagnosis of a first episode of Acute Retrobulbar Optic Neuritis.

Please answer the following questions regarding the treatment of this patient

• 1) At what visual acuity would you initiate steroids in this patient?

  • ○ Better than 6/24

  • ○ 6/24 – 6/60

  • ○ Less than 6/60

  • ○ I would initiate steroid treatment regardless of the visual acuity

  • ○ I would not initiate steroid treatment for this patient

• 2) Would you routinely:

  • ○ Treat as an inpatient

  • ○ Day services administration of treatment as an outpatient

  • ○ Treat solely as an outpatient

• 3) What would be your preferred route and dose of initial steroid therapy?

  • ○ 1g IV Methylprednisolone

  • ○ 1mg/kg per os prednisolone

  • ○ No steroid treatment

  • ○ Other steroid regime (please specify)

• 4) Initial steroid treatment routinely given for:

  • ○ 3 days

  • ○ 5 days

  • ○ More than 5 days

• 5) Your preferred dosing schedule for IVI Methylprednisolone:

  • ○ Once daily

  • ○ 500mg 12 hourly

  • ○ 250mg 6 hourly

• 6) Regarding per os steroid following initial treatment:

  • ○ Taper to a complete stop in 11 days

  • ○ Continue 1mg/kg po prednisolone for 11 days then taper

  • ○ No per os steroid after initial treatment

  • ○ Other (please specify)

• 7) Would you prescribe gastric protection?

  • ○ Yes

  • ○ No

• 8) Would you prescribe calcium supplements?

  • ○ Yes

  • ○ No

• 9) Which radiological investigations would you routinely order for this case? (multiple options allowed)

  • ○ CT brain and orbits

  • ○ CT brain and orbits with contrast

  • ○ MRI brain and orbits

  • ○ MRI brain and orbits with contrast

  • ○ Chest Xray

  • ○ None

• 10) Which laboratory investigations would you routinely order for this case? (multiple options allowed)

  • ○ Lumbar puncture

  • ○ Full blood count

  • ○ Urea and electrolytes

  • ○ ESR and CRP

  • ○ Syphillis serology

  • ○ Thyroid function tests

  • ○ Borrelia burgdorferi

  • ○ HSV

  • ○ TB

  • ○ HIV

  • ○ Autoimmune screen

  • ○ NMO antibody

  • ○ None

• 11) Regarding electrophysiology and field testing, which would you routinely order for this case?

  • ○ Visual evoked potential (VEP)

  • ○ Electroretinogram (ERG)

  • ○ Humphrey visual fields (HVF)

  • ○ Goldmann perimetry

  • ○ None

• 12) Would you mention the possible diagnosis of Multiple Sclerosis to the patient?

  • ○ Yes

  • ○ No

• 13) What is your current professional status?

  • ○ Consultant Neurologist

  • ○ Neurology trainee

  • ○ Consultant Ophthalmologist

  • ○ Medical Ophthalmologist

  • ○ Ophthalmology trainee

• 14) Would you treat this patient?

  • ○ Yes, I would treat this patient

  • ○ Yes, I would treat this patient but request an opinion from a Neuro-Ophthalmologist

  • ○ Yes, I would treat this patient but request an opinion from a Neurologist

  • ○ Yes, I would treat this patient but request an opinion from a Neuro-Ophthalmologist and a Neurologist

  • ○ Yes, but under supervision as I am a trainee

  • ○ No, I would refer to a Neuro-Ophthalmologist

  • ○ No, I would refer to a Neurologist

  • ○ No, I would refer to a Neuro-Ophthalmologist and a Neurologist

Note: respondents that selected ‘I would not initiate steroid treatment for this patient’ for the first questions were allowed to skip to the investigations section (question 9) of the questionnaire.