Childhood Optic Neuritis Treatment & Management

Updated: Nov 02, 2021
  • Author: Honey H H Herce, MD; Chief Editor: Edsel B Ing, MD, PhD, MBA, MEd, MPH, MA, FRCSC  more...
  • Print
Treatment

Approach Considerations

Optic neuritis may be a primary manifestation of an underlying disorder such as MS or a system autoimmune condition. Recurrence of ON occurs in approximately one third of patients. [1]

The prognosis for visual recovery is excellent in adults with or without medical therapy, as found in the Optic Neuritis Treatment Trial (ONTT). [12] The first pilot study of pediatric optic neuritis was launched in 2016, a 4-year study of children aged 3-15 years with acute optic neuritis in one or both eyes. [10] Data are not yet available from this trial.

Oral corticosteroids should not be used in treatment, as data from the Optic Neuritis Treatment Trial indicate that they increase the risk for optic neuritis relapse. [10]

Next:

Medical Care

The established treatment for children with optic neuritis is intravenous methylprednisolone 30 mg/kg per day (maximum 1 g daily) for 3-5 days. While steroids are not expected to change the medical outcome of an optic neuritis episode, they increase the speed of recovery to baseline. [1]

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. Specifically, studies have indicated good recovery of high-contrast visual acuity in children. [1] In children with optic neuritis, pulse steroids may speed recovery from 7 weeks to 2 weeks. This may be valuable to avoid psychosocial challenges, including the need to make up schoolwork, or affect other tasks because of visual limitations. [1]

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 (PLEX) is favored in those cases, but intravenous immune globulin (IVIG) has also been used. [11, 37]  For (MOG-IgG+) Seropositive Demyelinating Disease, current first-line treatment includes either intravenous corticosteroids, IVIG, or PLEX at the discretion of their managing team, however further data is needed on which method helps prevent relapse. [37]

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

Table 4. Equivalent Doses of Commonly Used Corticosteroid Medications (Open Table in a new window)

Corticosteroid Drug

Approximate Equivalent Dose

Prednisone

5 mg

Prednisolone

5 mg

Methylprednisolone

4 mg

Dexamethasone

0.75 mg

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

Previous
Next:

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. An immunologist should also be consulted for children with underlying immunologic pathology.

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

Previous
Next:

Long-Term Monitoring

Children who do develop MS may be more likely to develop disability at a younger age. Monitoring patients who had no associated neurologic signs or symptoms at the time of their optic neuritis will allow early diagnosis. Treatment of those patients for early onset MS with the disease modifying agents that are used in adults may be an option.

If optic neuritis is a suspected first manifestation of an underlying disorder, prophylactic treatment must be dictated by the causative disorder. For example, with rheumatologic disorders, steroids and long-term immunotherapy may prevent the recurrence of optic neuritis or other inflammatory CNS events.

Recurrence of optic neuritis during or shortly after the discontinuation of steroids indicates a steroid-dependent optic neuritis and requires reevaluation and a more prolonged taper of corticosteroids.

Previous
Next:

Further Outpatient Care

Outpatient follow-up care should include monitoring both visual recovery and recovery from neurologic or systemic disorders that were associated with optic neuritis.

Previous