Childhood Optic Neuritis Treatment & Management

  • Author: Martha P Schatz, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Dec 5, 2011
 

Medical Care

The prognosis for visual recovery is excellent in adults with or without medical therapy, as found in the Optic Neuritis Treatment Trial (ONTT).

No prospective study of the prognosis for visual recovery in children is available; most, but not all, studies of children have found that visual recovery is good. However, some authors, including those of Walsh & Hoyt's Clinical Neuro-ophthalmology, believe that a greater prevalence of steroid-responsive and steroid-dependent optic neuritis exists in children and routinely treat all their patients with high-dose corticosteroids.

In the ONTT, high-dose steroids consisted of methylprednisolone 250 mg administered intravenously every 6 hours for 3 days, followed by oral prednisone 1 mg/kg daily for 11 days.

No systematic study defining high-dose corticosteroids in childhood optic neuritis has been conducted. Walsh & Hoyt's Clinical Neuro-ophthalmology recommends methylprednisolone 1-2 mg/kg for 3-5 days, followed by a longer taper. Farris and Pickard used doses of methylprednisolone, ranging from 0.25-6.26 mg/kg, with one half of patients receiving doses of 125 mg or 250 mg every 6 hours for 5 days, followed by a taper.

The author favors methylprednisolone 125-250 mg/kg administered intravenously every 6 hours for initial therapy.

Treatment of the initial event in neuromyelitis optica, whether it is optic neuritis or myelitis, also uses high-dose intravenous steroids, but refractory cases are common and other therapies may be needed. Currently, plasma exchange is favored in those cases, but intravenous immune globulin (IVIg) has also been used.

The equivalent doses of 4 commonly used drugs to treat optic neuritis are provided in Table 2.

Table 2. Equivalent Doses of Commonly Used Corticosteroid Medications (Open Table in a new window)

Corticosteroid DrugApproximate Equivalent Dose
Prednisone5 mg
Prednisolone5 mg
Methylprednisolone4 mg
Dexamethasone0.75 mg

See related CME at Optic Neuritis: Diagnosis, Treatment, and Prognosis.

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Consultations

The management of a child with optic neuritis is a combined effort by the ophthalmologist and the neurologist. Ophthalmologic input is required to distinguish between optic neuritis and neuroretinitis and to monitor visual response. Neurologic input is required to evaluate possible generalized CNS involvement and to make appropriate decisions and recommendations based on the future risk of MS.

Children taking etanercept or other tumor necrosis factor (TNF) inhibitors should be reevaluated by their rheumatologists.

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Contributor Information and Disclosures
Author

Martha P Schatz, MD  Chief, Pediatric Ophthalmology Service, Clinical Professor of Ophthalmology, University of Texas Health Science Center at San Antonio

Martha P Schatz, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association of Pediatric Ophthalmology & Strabismus (AAPOS), North American Neuro-Ophthalmology Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

John E Carter, MD  Associate Professor, Department of Medicine, Assistant Professor, Department of Ophthalmology, University of Texas Health Science Center at San Antonio

John E Carter, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Gerhard W Cibis, MD  Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas School of Medicine

Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Ophthalmological Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Brian R Younge, MD  Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Ralph Garzia, OD  Assistant Dean for Clinical and Academic Programs, Associate Professor, College of Optometry, University of Missouri at St Louis

Ralph Garzia, OD is a member of the following medical societies: American Academy of Optometry and American Optometric Association

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

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Optic disc swelling in the right eye and left eye in a child with bilateral optic neuritis.
Neuroretinitis in the right eye of an adolescent with cat scratch disease. The optic nerve is swollen, and a deposition of yellowish exudate in the nerve fiber layer of the macula produces a macular star.
T1 contrast enhanced axial section of an MRI of the orbital optic nerve of a child with optic neuritis on the left side. The arrows point to the left optic nerve that enhances along its entire orbital course.
T1 contrast enhanced coronal section of the MRI of the orbital optic nerve. The arrow points to the enhancing left optic nerve.
T1 contrast enhanced axial section of an MRI of the intracranial optic nerves. Enhancement of both optic nerves is seen. The arrow indicates the left optic nerve.
T1 contrast enhanced coronal section of the MRI showing the optic nerves that both enhance. The arrow points to the left optic nerve.
T2 axial section of an MRI through the cerebral hemisphere of a boy with bilateral optic neuritis. Note high-signal abnormalities in the cerebral white matter that are most prominent in the posterior hemispheres. This is suspicious for mild acute disseminated leukoencephalitis.
T2 axial sections of MRI of a man with optic neuritis showing scattered white matter lesions. The arrows point to 2 examples of the numerous lesions.
Table 1. Comparison of Features of Optic Neuritis in Adults and Children
Adult Optic NeuritisPediatric Optic Neuritis
UnilateralBilateral
Retrobulbar optic neuritisPapillitis
Commonly associated with pain on eye movementsCommonly associated with headache
Most often idiopathicMost often postinfectious or postimmunization
High probability of recurrent inflammatory demyelinating events in the CNS and a diagnosis of MSLow probability of recurrent demyelinating events and a diagnosis of MS
Table 2. Equivalent Doses of Commonly Used Corticosteroid Medications
Corticosteroid DrugApproximate Equivalent Dose
Prednisone5 mg
Prednisolone5 mg
Methylprednisolone4 mg
Dexamethasone0.75 mg
Table 3. Life-Table Analysis of the Risk for Development of MS in Children With an Isolated Attack of Optic Neuritis[4]
AgeRisk for Development of MS
10 years13%
20 years19%
30 years22%
40 years26%
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