Adult Optic Neuritis Treatment & Management

Updated: Jul 01, 2019
  • Author: Erhan Ergene, MD; Chief Editor: Edsel Ing, MD, MPH, FRCSC  more...
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Treatment

Approach Considerations

Finding professional help early in the course of optic neuritis (ON) is important. The Optic Neuritis Treatment Trial (ONTT) was a carefully performed, randomized, clinical trial that yielded useful information. Despite the ONTT, the treatment of optic neuritis remains somewhat controversial. [13, 12] From a vision standpoint, observation without steroid treatment versus intravenous (IV) steroid treatment showed no difference in ultimate visual outcome at the 5-year mark. [14]

Eculizumab, a monoclonal antibody that targets C5, is the first drug approved by the FDA for adults with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin-4 (AQP4) antibody–positive. Approval was based on the PREVENT clinical trial. Results showed eculizumab reduced the risk of NMOSD relapse by 94.2% compared with placebo (P< 0.0001). Nearly 98% of eculizumab-treated patients were relapse-free at 48 weeks compared with 63.2% of patients in the placebo arm. Additionally, compared with placebo, eculizumab reduced the adjudicated on-trial annualized relapse rate by 95.5% (P< 0.0001). [15]

Early reports with a small number of patients found some benefit with plasma exchange in acute, severe optic neuritis. Further controlled studies are recommended. In 2016, a randomized controlled trial of erythropoietin in the treatment of optic neuritis was initiated. [51]

Rituximab therapy is considered to be among the most efficient treatments of neuromyelitis optica spectrum disorders (NMOSDs), "even in the absence of class I studies." [52] In a case series of 20 patients with highly relapsing NMO, Kim et al reported significantly reduced relapse rates and clinical stabilization or improvement with mitoxantrone treatment. [53] Further studies conducted in a prospective and controlled fashion are required to determine whether mitoxantrone is a viable treatment option.

Inpatient care

Patients with NMO often require supportive care, as they are prone to many complications, such as deep venous thrombosis, pulmonary embolism, urinary tract infection, decubiti, and contractures related to the myelopathy. Mechanical ventilation may be needed due to respiratory compromise.

Consultations

Consultations with ophthalmology and neurology are recommended for complete evaluation and treatment of suspected optic neuritis cases.

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Steroid Therapy

The ONTT protocol used intravenous steroids (methylprednisolone 250 mg qid for 3 days) with oral steroid taper and showed a decreased the short-term risk of development of MS in patients with central nervous system (CNS) white matter plaques, but they had no long-term protective benefit from MS.

IV steroids do little to affect the ultimate visual acuity in patients with optic neuritis, but they do speed the rate of recovery. Some clinicians advocate IV steroids in patients with severe visual loss or bilateral visual loss.

IV steroids are sometimes administered in an outpatient setting or at home. Admission to the hospital is recommended for the duration of high-dose intravenous steroid treatment because of the potential risk of serious adverse effects from this treatment.

The ONTT showed strong evidence against the use of conventional-dose oral steroid monotherapy in the treatment of optic neuritis, since oral steroids alone increased the rate of optic neuritis recurrence. [54, 55]

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Medical Care

In patients at high risk of developing MS, consultation with a neurologist for possible immune prophylaxis with beta-interferon or glatiramer acetate should be considered.

Dress polycarbonate safety glasses are an option in patients whose vision does not completely recover.

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