What is the recommended steroid treatment for optic neuritis?

Recommended Steroid Treatment for Optic Neuritis

High-dose intravenous methylprednisolone at 1000 mg/day for 3 days is the recommended first-line treatment for optic neuritis. 1

First-Line Treatment Protocol

• IV methylprednisolone should be administered at 1000 mg/day for 3 days as the initial treatment for typical optic neuritis 1
• Treatment should be initiated promptly, as delays beyond 2 weeks are associated with poorer outcomes 1, 2
• Higher doses of IV methylprednisolone (up to 30 mg/kg, not exceeding 1000 mg/day) may be used in certain cases 1

Treatment Based on Optic Neuritis Type

Typical Optic Neuritis (MS-associated)

• IV methylprednisolone accelerates visual recovery but does not affect final visual outcome 1, 3
• Oral corticosteroids alone are not recommended as they may increase the risk of new episodes of optic neuritis 4

Atypical Optic Neuritis (Non-MS associated)

• For optic neuritis associated with Systemic Lupus Erythematosus (SLE), combination therapy with pulse IV methylprednisolone and IV cyclophosphamide is recommended 1
• For Neuromyelitis Optica Spectrum Disorder (NMOSD)-associated optic neuritis:
  • Initial treatment remains IV methylprednisolone at 1000 mg/day for 3-5 days 2
  • Long-term immunosuppressive therapy is typically required to prevent relapses 2

Second-Line Treatments for Refractory Cases

• Plasma exchange (PLEX) should be considered in severe cases not responding to IV steroids 1, 2, 5
• Rituximab (RTX) is recommended for refractory cases, particularly in NMOSD-associated optic neuritis 1, 2
• Other immunosuppressants that may be used include:
  • Azathioprine (AZA) 1, 2
  • Mycophenolate mofetil (MMF) 6, 2

Monitoring and Follow-up

• Regular ophthalmological evaluations including visual acuity, visual fields, and funduscopy are necessary to monitor treatment response 1, 2
• Visual-evoked potentials may detect bilateral optic nerve damage before it becomes clinically apparent 1
• MRI of the brain and orbits with contrast is essential for diagnosis and to rule out other conditions 1

Important Caveats and Pitfalls

• Relapses are common (50-60%) during corticosteroid dose reduction, highlighting the need for maintenance immunosuppressive therapy in some cases 1
• Patients with MOG-IgG antibodies should be tested after the first recurrence of optic neuritis, as standard MS treatments may worsen outcomes in these patients 6
• Low-dose oral steroids alone are not recommended as primary treatment for optic neuritis 4, 3
• For patients with antiphospholipid antibodies not responding to immunosuppressive therapy, anticoagulation may be considered 1

Special Populations

• In pediatric optic neuritis, treatment should be adjusted based on weight (typically 30 mg/kg/day of methylprednisolone) 1
• For optic neuritis during pregnancy, treatment decisions should carefully weigh risks and benefits, with consultation from maternal-fetal medicine specialists 7