What is the diagnosis and treatment for optic neuritis (inflammation of the optic nerve)?

From the Guidelines

Optic neuritis should be diagnosed and treated promptly with high-dose intravenous methylprednisolone, followed by oral prednisone, and evaluated with MRI of the brain and orbits with contrast to look for demyelinating lesions. The diagnosis of optic neuritis typically involves a clinical suspicion based on symptoms such as sudden vision loss, pain with eye movement, and reduced color vision. According to the study by 1, MRI of the orbits and head without and with contrast are the primary imaging studies for initial assessment, serving to evaluate for abnormal enhancement and signal changes within the optic nerve and to evaluate the brain for associated intracranial demyelinating lesions. Some key points to consider in the diagnosis and treatment of optic neuritis include:

• The use of MRI to evaluate for demyelinating lesions, which is a strong predictor of the subsequent development of multiple sclerosis 1
• The importance of differentiating between optic neuritis and other conditions, such as neuromyelitis optica, which can be done with MRI and laboratory tests 1
• The treatment of optic neuritis with high-dose intravenous methylprednisolone, followed by oral prednisone, which speeds visual recovery but does not affect long-term outcomes
• The need for prompt evaluation and treatment, as well as monitoring for recurrence and development of other neurological symptoms that might indicate MS. It's also worth noting that, as mentioned in the study by 1, SLE-related optic neuritis is associated with poor visual outcome, and only 30% of patients maintain a visual acuity greater than 20/25, and that pulse intravenous methylprednisolone in combination with intravenous cyclophosphamide is recommended in such cases. However, the most recent and highest quality study 1 provides the best guidance for the diagnosis and treatment of optic neuritis.

From the FDA Drug Label

6 Ophthalmic Diseases Severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa such as: ... Optic neuritis The diagnosis of optic neuritis is not explicitly stated in the label, but optic neuritis is listed as one of the conditions for which prednisone is indicated.

• The treatment for optic neuritis, according to the label, may involve prednisone 2.
• The label does not provide information on how to diagnose optic neuritis, only that prednisone can be used to treat it.

From the Research

Diagnosis of Optic Neuritis

• Optic neuritis is often diagnosed based on clinical presentation, including subacute loss of vision, dense visual field loss, and afferent pupillary defect (APD) in unilateral cases 3
• Neuroimaging, such as magnetic resonance imaging (MRI), is necessary to exclude other causes of optic neuropathy and to assess for signal abnormalities that may indicate a higher risk of developing multiple sclerosis 4
• Serologic evaluation may also be necessary to exclude infectious or neoplastic processes 3

Treatment of Optic Neuritis

• High-dose corticosteroids, such as intravenous methylprednisolone, are the mainstay of treatment for acute optic neuritis 4, 5, 6, 7
• Treatment typically consists of 3 to 5 days of intravenous methylprednisolone, followed by a prolonged oral corticosteroid taper 3
• Oral high-dose methylprednisolone (1 g per day for 3 to 5 days) has also been shown to be effective in improving visual function parameters 5
• Plasma exchange (PLEX) and intravenous immunoglobulin (IVIG) may be considered in cases with atypical features or unfavorable outcomes 6
• The treatment goal is to hasten visual recovery, although high-dose corticosteroids may not affect the final visual outcome 7

Special Considerations

• Pediatric optic neuritis may require a prolonged course of oral steroids (2-4 weeks) to avoid recurrence 3
• Atypical optic neuritis may require special consideration, such as early addition of other therapeutic agents or tapering the steroid very slowly 6
• The presence of white matter lesions on brain MRI may indicate a higher risk of developing multiple sclerosis and may influence treatment decisions 4, 7