What is the diagnosis and treatment for a 60-year-old male with retrobulbar optic neuritis and a recent episode of transient myopathy?

From the Guidelines

For a 60-year-old male with retrobulbar optic neuritis and a recent episode of transient myopathy, I strongly recommend urgent neurological and ophthalmological evaluation to rule out multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD), as suggested by the American College of Radiology criteria 1. The patient's presentation of optic neuritis with myopathy is atypical for MS and raises concern for other conditions like NMOSD, myelin oligodendrocyte glycoprotein antibody disease (MOGAD), or paraneoplastic syndromes.

• Initial treatment should include high-dose intravenous methylprednisolone 1000mg daily for 3-5 days, followed by an oral prednisone taper starting at 60mg daily and decreasing by 10mg every 3 days, as this approach has been shown to be effective in reducing inflammation and improving outcomes in patients with optic neuritis 1.
• The patient should undergo MRI imaging of the brain and orbits with contrast, complete spine MRI, visual evoked potentials, optical coherence tomography, and blood tests including AQP4 and MOG antibodies, vitamin B12, folate, ESR, CRP, and syphilis serology to establish a definitive diagnosis and guide further management.
• Close monitoring for visual recovery is essential, with most improvement occurring within the first 3 months, and long-term immunomodulatory therapy may be necessary depending on the final diagnosis, as highlighted by the revised McDonald criteria and MAGNIMS consensus guidelines 1. Urgent evaluation and treatment are crucial to prevent long-term visual impairment and to address potential underlying conditions that may be contributing to the patient's symptoms, as emphasized by the American College of Radiology criteria 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosis and Treatment of Retrobulbar Optic Neuritis

• Retrobulbar optic neuritis is an inflammatory disease of the optic nerve that can present with an abrupt loss of vision 2, 3.
• The diagnosis of primary demyelinating retrobulbar neuritis must be made with caution as a diagnosis of exclusion 4.
• High-dose methylprednisolone can speed up recovery of visual function and lower the recurrence rate two years after treatment, but this protective effect may not be demonstrated after three years 4.

Corticosteroids for Treating Optic Neuritis

• There is no conclusive evidence of benefit in terms of recovery to normal visual acuity, visual field, or contrast sensitivity with either intravenous or oral corticosteroids at the doses evaluated in trials included in this review 2, 3.
• Low-dose oral corticosteroids are not only ineffective but also associated with a higher rate of recurrences compared to high-dose intravenous methylprednisolone 4.
• The risk ratio of normal visual acuity, contrast sensitivity, and visual field with intravenous corticosteroids compared with placebo was not significantly different from 1 2, 3.

Relationship with Multiple Sclerosis

• Retrobulbar optic neuritis can be the initial manifestation of multiple sclerosis, and a number of diagnosed multiple sclerosis patients was high in a relatively short period of observation 5.
• Progressive optic neuropathy after retrobulbar neuritis in multiple sclerosis can be evaluated using optical coherence tomography (OCT) and magnetic resonance imaging (MRI) 6.
• The retinal nerve fiber layer (RNFL) thickness and macular volume were significantly worse in eyes post-optic neuritis compared to eyes without previous optic neuritis 6.