What is the recommended treatment for optic neuritis?

Optic Neuritis Treatment

High-dose intravenous methylprednisolone at 1000 mg/day for 3 days is the recommended first-line treatment for optic neuritis, and treatment should be initiated promptly as delays beyond 2 weeks are associated with significantly poorer visual outcomes. 1, 2

First-Line Treatment Protocol

• Administer IV methylprednisolone 1000 mg/day for 3 days as the standard acute treatment 1, 2
• Higher doses up to 30 mg/kg (not exceeding 1000 mg/day) may be used in certain cases, though the standard 1000 mg dose is typically sufficient 1, 2
• Following IV therapy, a prolonged oral prednisone taper (typically 2-4 weeks) is recommended to prevent relapses, which occur in 50-60% of cases during steroid reduction 1, 2

The landmark Optic Neuritis Treatment Trial demonstrated that IV methylprednisolone accelerates visual recovery and results in slightly better visual function at 6 months, while oral prednisone alone is ineffective and actually increases the risk of recurrent optic neuritis episodes. 3

Critical Timing Considerations

• Initiate treatment as soon as possible—delays beyond 2 weeks correlate with worse visual outcomes and increased risk of severe neurological deficits 2, 4
• Duration of 3 days is typically adequate; extending to 5-7 days shows no additional benefit in visual recovery, suggesting a ceiling effect 5

Treatment Based on Underlying Etiology

Standard Demyelinating Optic Neuritis

• Use the standard 3-day IV methylprednisolone protocol followed by oral taper 1, 2
• Monitor for progression to multiple sclerosis, as approximately 50% will develop clinically definite MS within 15 years 4

SLE-Associated Optic Neuritis

• Combine pulse IV methylprednisolone with IV cyclophosphamide for this population 1, 2
• Visual prognosis is significantly worse—only 30% maintain visual acuity greater than 20/25 1
• For patients with antiphospholipid antibodies not responding to immunosuppression, consider anticoagulation 1, 2

Neuromyelitis Optica Spectrum Disorder (NMOSD)

• Begin with IV methylprednisolone 1000 mg/day for 3-5 days 2
• Long-term immunosuppressive therapy is mandatory to prevent relapses 2
• Rituximab demonstrates superior efficacy compared to azathioprine for preventing relapses in refractory cases 1, 2

Pediatric Optic Neuritis

• Dose methylprednisolone at 30 mg/kg/day (typically 4-30 mg/kg range) based on body weight 2, 6
• Use a prolonged oral steroid taper (2-4 weeks) as recurrence is particularly common in children 6

Second-Line Treatments for Refractory Cases

• Plasma exchange (PLEX) should be considered for severe cases with complete lack of response to IV steroids or progressive vision loss 1, 2, 4
• Rituximab is the preferred agent for refractory NMOSD-associated optic neuritis 1, 2
• Mycophenolate mofetil or azathioprine may serve as steroid-sparing maintenance agents 1, 2

Essential Diagnostic Workup

• Obtain MRI of brain and orbits with contrast to assess for demyelinating lesions and evaluate MS risk 1, 2
• Repeat MRI at 3-6 months to detect new lesions and reassess MS progression risk 4
• Visual-evoked potentials can detect bilateral optic nerve involvement before clinical manifestation 1, 2, 4

Critical Pitfalls to Avoid

• Never use oral prednisone alone as initial therapy—the Optic Neuritis Treatment Trial definitively showed this increases recurrence risk without improving outcomes 3
• Do not use corticosteroids for optic neuritis in patients with MOG-IgG antibodies after first recurrence, as standard MS treatments may worsen outcomes in this population 2
• Avoid high-dose IV methylprednisolone in patients with prior toxic hepatitis from methylprednisolone, as recurrence occurs with re-challenge 7
• Do not discontinue monitoring prematurely—relapses are common (50-60%) and require immediate retreatment 1, 2, 4

Monitoring Requirements

• Perform ophthalmological evaluations every 4-6 weeks initially, including visual acuity, visual fields, funduscopy, and contrast sensitivity 2, 4
• Any new vision loss in either eye or development of other neurological symptoms (weakness, sensory changes, ataxia) warrants immediate repeat MRI and consideration of repeat IV methylprednisolone 4
• Test for MOG-IgG antibodies after the first recurrence to guide subsequent treatment decisions 2