Treatment of optic neuritis

The ONTT demonstrated that corticosteroid therapy for optic neuritis had no long-
term beneficial effect on vision, although the use of intravenous
methylprednisolone, 250 mg every 6 hours for 3 days, followed by oral prednisone, 1
mg/kg/day for 11 days, sped recovery by 1–2 weeks. Patients receiving oral
prednisone alone did not have any benefit to vision and incurred a recurrence rate
double that of the other groups; therefore, this treatment is not recommended.
Intravenous therapy demonstrated a reduction in the rate of development of
clinically definite MS after the initial optic neuritis only in the subgroup of
patients with MRI scans showing 2 or more white matter lesions. At 2 years, these
patients’ risk for MS was 36% untreated, 16% treated. By follow-up year 3 and
thereafter, however, this protective effect was lost.

With unclear benefits, the value of therapy and of additional diagnostic evaluation
for MS must be assessed individually. In cases in which a rapid return of vision is
essential (eg, monocular patient, patient with an occupational need), intravenous
methylprednisolone on an outpatient basis may be Figure 4-19 A, Disc photograph in
retrobulbar optic neuritis, showing normal appearance. B, A central scotoma is
shown on automated perimetry results. C, T1-weighted axial MRI scan of the orbits
with fat-suppression and gadolinium administration, showing enhancement of the
right intraorbital optic nerve (arrow). D, T2-weighted axial MRI scan of the brain,
demonstrating multiple white matter hyperintensities (arrows) consistent with
demyelination. (Parts A, B courtesy of Steven A. Newman, MD; part C courtesy of
Michael S. Lee, MD; part D courtesy of Anthony C. Arnold, MD.) considered;
otherwise, treatment for vision recovery is not required. An MRI scan is generally
performed to assess MS risk, but additional evaluation, including CSF analysis, is
probably best referred to a consulting neurologist. The value of intravenous
corticosteroids alone to reduce the long-term risk of MS is unproven.

Immunomodulatory therapy is of proven benefit for reducing morbidity in the

relapsing-remitting form of MS, and studies have shown that such drugs delay the
conversion of patients with acute optic neuritis or other clinically isolated
syndrome with high-risk MRI characteristics to definite MS (see Chapter 14 for a
discussion of MS treatment.)