From the Guidelines
Optic neuritis should be diagnosed and treated with high-dose intravenous methylprednisolone (typically 1000 mg daily for 3-5 days), followed by oral prednisone (1 mg/kg/day) tapered over 11 days, and an MRI of the brain and orbits with contrast to evaluate for multiple sclerosis (MS) and other potential causes. This approach is supported by the most recent and highest quality study, which emphasizes the importance of prompt and accurate diagnosis to guide treatment and improve outcomes 1.
Diagnosis and Treatment
The diagnosis of optic neuritis typically involves a clinical evaluation, including a thorough medical history and physical examination, as well as diagnostic tests such as MRI of the brain and orbits with contrast to evaluate for abnormal enhancement and signal changes within the optic nerve, and to assess for associated intracranial demyelinating lesions 1. Blood tests, including ANA, ESR, CRP, syphilis serology, and Lyme testing in endemic areas, may also be useful in ruling out other inflammatory or infectious causes.
Key Considerations
- MRI of the brain and orbits with contrast is a crucial diagnostic tool for evaluating optic neuritis and assessing for potential underlying conditions such as multiple sclerosis (MS) 1.
- High-dose intravenous methylprednisolone is a common treatment approach for optic neuritis, which can help speed visual recovery, although final visual outcomes are generally similar with or without treatment.
- Monitoring for worsening symptoms and potential development of other neurological symptoms is essential during the acute phase of optic neuritis.
- Blood tests to rule out other inflammatory or infectious causes may include ANA, ESR, CRP, syphilis serology, and Lyme testing in endemic areas.
Additional Considerations
In some cases, optic neuritis may be associated with underlying conditions such as systemic lupus erythematosus (SLE) or neuromyelitis optica, which may require additional diagnostic testing and treatment approaches 1. However, the primary approach to diagnosis and treatment remains focused on high-dose intravenous methylprednisolone and MRI evaluation, with consideration of additional testing and treatment as needed based on individual patient circumstances.
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 a constellation of symptoms and signs, including pain on eye movement in one eye and subacute visual loss 3
- The diagnosis can be supported by the presence of a mildly edematous optic disc in approximately one-third of patients 3
- A direct pupillary light reflex that is weaker in the affected eye can also indicate unilateral optic neuritis 3
- Magnetic resonance imaging (MRI) of the brain can be used to assess the risk of developing multiple sclerosis in patients with optic neuritis 4, 3
Treatment of Optic Neuritis
- High-dose intravenous corticosteroids (IVCS) are the standard treatment for acute optic neuritis, as established by the Optic Neuritis Treatment Trial (ONTT) 5
- IVCS can hasten visual recovery in acute typical optic neuritis, but do not affect the final visual outcome 5
- Treatment with a three-day course of high-dose intravenous methylprednisolone, followed by a short course of prednisone, can reduce the rate of development of multiple sclerosis over a two-year period 4
- In pediatric patients, treatment typically consists of 3 to 5 days of intravenous methylprednisolone, followed by a prolonged oral corticosteroid taper to avoid recurrence 6
- For patients judged to be at high risk of developing multiple sclerosis, immune prophylaxis with beta-interferon or glatiramer acetate may be recommended 3
Considerations for Treatment
- The decision to treat optic neuritis with steroids should be based on the potential benefits and risks, particularly in patients with significant vision loss, severe pain, and/or white matter lesions on brain MRI 5
- Atypical forms of optic neuritis and other optic nerve diseases may require special treatment 3
- The role of race, route of administration, and combination of IVCS with other therapies has been examined in recent studies, but high-dose IVCS remains the cornerstone of treatment for acute optic neuritis 5