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REVIEW

CURRENTOPINION Should patients with optic neuritis be treated

with steroids?

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1040-8738 Copyright � 2015 Wolte

Devin D. Mackay

Purpose of review

Optic neuritis is the most common cause of optic neuropathy in young adults. High-dose intravenouscorticosteroids (IVCS) were established as the standard of treatment for acute optic neuritis via the OpticNeuritis Treatment Trial (ONTT), with its first findings published more than 20 years ago. Subsequentstudies have further clarified the role of corticosteroids in the treatment of acute optic neuritis.

Recent findings

Recent clinical research has confirmed existing knowledge of the efficacy and limitations of corticosteroidsin the treatment of optic neuritis. Recent studies have examined the role of race, route of administration andcombination of IVCS with other therapies. Current evidence continues to support high-dose IVCS as thecornerstone of treatment of acute optic neuritis.

Summary

High-dose IVCS are effective in hastening visual recovery in acute typical optic neuritis, but do not affectthe final visual outcome. In optic neuritis patients, IVCS may delay progression to clinically definite multiplesclerosis (CDMS) at 2 years, but not at 5 or 10 years. It is reasonable to recommend high-dose IVCS foracute optic neuritis patients with significant vision loss, severe pain and/or white matter lesions on brainMRI in whom the potential for benefit outweighs the risks.

Keywords

corticosteroids, multiple sclerosis, optic neuritis, steroids

Indiana University School of Medicine, Indianapolis, Indiana, USA

Correspondence to Devin D. Mackay, MD, Departments of Neurology,Ophthalmology, and Neurosurgery, Indiana University School ofMedicine, 355W. 16th Street, Suite 3200, Indianapolis, IN 46202,USA. Tel: +1 317 948 5450; fax: +1 317 962 2141;e-mail: [email protected]

Curr Opin Ophthalmol 2015, 26:439–444

DOI:10.1097/ICU.0000000000000197

INTRODUCTION

Optic neuritis is defined as dysfunction of the opticnerve related to inflammation. It is the most com-mon cause of optic neuropathy among youngadults and is the presenting sign of multiplesclerosis in approximately 20–25% of cases [1

&

].The clinical hallmarks of typical optic neuritisinclude subacute, central vision loss in one eyethat may progress over 1–2 weeks, accompaniedby pain with eye movements in more than 90% ofcases, a relative afferent pupillary defect in unilat-eral cases, and impairment of colour vision out ofproportion to visual acuity. Optic neuritis is aclinical diagnosis, but MRI of the brain and orbitsis useful, both in confirming the presence of opticnerve inflammation and in screening for radio-graphic evidence of multiple sclerosis (Fig. 1).MRI has also proven to be the single best predictorof the future risk of multiple sclerosis in patientswith optic neuritis [2].

Since the publication of the Optic NeuritisTreatment Trial (ONTT), a multicentre, prospec-tive, randomized, placebo-controlled clinical trial

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in which intravenous corticosteroids (IVCS) andoral steroids were evaluated in patients with acuteoptic neuritis [3], IVCS have been routinely used inthe treatment of acute optic neuritis. The necessityof treatment of idiopathic demyelinating opticneuritis is debatable, as IVCS have been demon-strated to hasten visual recovery and potentiallytemporarily delay the onset of multiple sclerosis,but have failed to show an effect on long-termvisual outcomes. The aim of this article is to reviewrecent evidence and offer reasonable criteria toguide the use of IVCS in the treatment of acuteoptic neuritis.

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KEY POINTS

� IVCS hasten the recovery of visual function in typicalacute optic neuritis and may decrease the risk ofdevelopment of CDMS at 2 years, but not at 5 or10 years.

� It is reasonable to offer high-dose IVCS in patients withtypical acute optic neuritis with significant vision loss,severe pain and/or T2 white matter hyperintensities onbrain MRI.

� No permanent beneficial effects of high-dose IVCShave been demonstrated in typical acute optic neuritistrials, emphasizing the role of IVCS as an optional, butpotentially very helpful, treatment for typical acuteoptic neuritis.

� Untreated atypical optic neuritis may lead toirreversible vision loss and urgent treatment withcorticosteroids may help prevent poor visual outcomes.

� Intermediate-dose oral corticosteroids (1 mg/kg/dayprednisone equivalent) have no role in the treatment oftypical acute optic neuritis.

Neuro-ophthalmology

CORTICOSTEROIDS FOR OPTIC NEURITIS

Glucocorticosteroids exert their immunosuppres-sant effects via a variety of cellular mechanismsrelevant to optic neuritis, at both genomic and non-genomic levels, with effects on blood–brain barrier

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(a)

(b)

(c)

FIGURE 1. MRI findings associated with optic neuritis. (a) T1 poof the proximal intraorbital portion of the right optic nerve (arrowenhancement of the intraorbital right optic nerve (arrow). (c) T2 Fof T2 hyperintensity in the periventricular cerebral white matter insclerosis. None of the lesions was enhancing on postcontrast ima

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integrity, leukocyte chemotaxis, immunoglobulinproduction, macrophage activation and cytokineproduction, among others [4,5]. Corticotrophinand cortisone were used with some benefit in avariety of neurologic disorders, including optic neu-ritis, in an uncontrolled study published in 1952,without any definite conclusions regarding efficacy[6]. Over the next several decades, others also eval-uated steroids in the treatment of optic neuritisand suggested a possible benefit [7,8]. In 1988, theresults of a small trial of 12 patients with opticneuritis treated with high doses of intravenous(i.v.) methylprednisolone were published, all ofwhom showed an improvement [9]. These studiespaved the way for the ONTT, which has arguablyinfluenced the treatment of acute optic neuritismore than any other published clinical trial [3].

THE OPTIC NEURITIS TREATMENT TRIAL

The ONTT included 457 patients between the agesof 18 and 46 years with visual symptoms lasting8 days or less and history and examination findingsconsistent with optic neuritis. Each patient wasrandomized to one of three study arms: placebo,250 mg of i.v. methylprednisolone every 6 h for3 days followed by oral prednisone at 1 mg/kg for11 days, or oral prednisone at 1 mg/kg for 14 days.The treatment regimen in both the i.v. and oralcorticosteroid groups included a 4-day oral taper.

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stcontrast fat suppressed axial images showing enhancements). (b) T1 postcontrast fat suppressed coronal images showingLAIR axial brain sequence in the same patient showing areasa pattern consistent with the patient’s known multiple

ges.

Volume 26 � Number 6 � November 2015

Should optic neuritis be treated with steroids? Mackay

Treatment with i.v. methylprednisolone was associ-ated with a more rapid recovery of visual func-tion. Methylprednisolone showed the mostbenefit within the first 15 days of follow-up, butby 6 months, the visual outcome of the i.v. meth-ylprednisolone group was only slightly better thanplacebo [3]. By 1 year, there was no difference invisual outcome in any of the groups [10]. Unexpect-edly, oral prednisone treatment was associatedwith an approximately two-fold higher rate ofrecurrent optic neuritis during 6-24 months offollow-up (27%) than either the i.v. methylpredni-solone group (13%) or the placebo group (15%). At10 years, the rate of recurrence of optic neuritiswas still higher in the oral prednisone group thanin the i.v. methylprednisolone group, but was nolonger significantly different from placebo [11]. At2 years, the rate of progression to clinically definitemultiple sclerosis (CDMS) was lower in the i.v.methylprednisolone group than either the placeboor oral steroid groups, although there was no differ-ence in the rates of multiple sclerosis betweengroups at 5 years [12]. During the trial, only twoout of 151 patients in the i.v. methylprednisolonegroup experienced serious, but transient, sideeffects: one with acute pancreatitis and the otherwith acute transient depression.

The results of the ONTT have been interpreted asshowing that IVCS are well tolerated and hastenvisual recovery following acute optic neuritis, inter-mediate doses (1 mg/kg/day) of oral prednisonealone increase the risk of recurrence of optic neuritisand i.v. steroids may delay the onset of CDMSwithin the first 2 years after optic neuritis.

A recent meta-analysis of high-dose IVCS in thetreatment of optic neuritis reiterated the findings ofthe ONTT in that it found no effect of IVCS on visualoutcomes at 6 months or 1 year [13].

FACTORS IN THE RESPONSE TOCORTICOSTEROID TREATMENT FOROPTIC NEURITIS

No studies have suggested that any specific sub-group of patients with typical acute optic neuritisis more likely to benefit from treatment withcorticosteroids than another. A recent reanalysisof data from the ONTT with regard to self-reportedblack race/ethnicity showed that black patientshad worse vision at the onset of optic neuritisand recovered at a faster rate than white patients,but the final vision was still worse in blackpatients. No interaction between race/ethnicityand treatment modality was found for either i.v.or oral steroids. Therefore, it is very unlikely thatblack race/ethnicity plays any significant role in

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the efficacy of steroid treatment for acute opticneuritis [14

&&

].

EFFECT OF CORTICOSTEROIDS ON THERISK OF OPTIC NEURITIS RECURRENCE

The finding of an increased risk of optic neuritisrecurrence following treatment with intermediatedoses of oral prednisone in the ONTT has been thesubject of criticism due to the purported lack of aplausible biological explanation, a marginal P-valuefor the finding, disagreement with the results of anearlier published study and alteration of the a-prioriassumptions of the trial to reach this conclusion[15]. Subsequent publications have addressed someof these criticisms. A retrospective, single-centrestudy of risk factors for idiopathic optic neuritisrecurrence in Chinese patients found a higher rateof recurrence in patients with unilateral optic neu-ritis (40 vs. 12% for bilateral optic neuritis) andthose treated with intermediate-dose (equivalentof �100 mg oral prednisone/day) corticosteroids(42 vs. 25% for >100 mg/day; P¼0.045) [16

&

]. Theauthors postulated that genomic effects of cortico-steroids, mediated by alterations in gene transcrip-tion, are most prominent at doses of 100 mg daily orless, while nongenomic effects predominate at dosesmore than 100 mg daily, accounting for the differ-ence in efficacy and optic neuritis recurrence riskbetween high-dose and intermediate-dose cortico-steroids. It is now a commonly accepted standard ofpractice that intermediate-dose oral corticosteroidsalone are not used in the treatment of typical acuteoptic neuritis.

HIGH-DOSE ORAL CORTICOSTEROIDS

Although the ONTT showed no role for intermedi-ate-dose (1 mg/kg daily) oral prednisone, there arelimited data to support the use of high doses of oralprednisone in the treatment of optic neuritis [17].Sixty patients were included in a single-centre,randomized, placebo-controlled trial that evaluatedoral methyprednisolone at a dose of 500 mg daily for3 days, followed by a 10-day oral taper. There was abeneficial effect on vision at 1 and 3 weeks followingthe initiation of treatment, but not at 8 weeks, andthere was no increased risk of demyelinating eventsin the treated group at 1 year [17]. The potential fordecreased costs and ease of administration associ-ated with high-dose oral instead of IVCS hasprompted interest in further research regardingthe efficacy of high-dose oral corticosteroids forthe treatment of optic neuritis. A clinical trial hasbeen completed evaluating optic neuritis recoveryfollowing randomized treatment with equivalent


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doses of i.v. or oral corticosteroids, although theresults have not yet been published (NCT01524250,clinicaltrials.gov). On the basis of currently availabledata, high-dose oral corticosteroids appear to be areasonable consideration in the treatment of acuteoptic neuritis when IVCS are contraindicated ornot available.

TIMING OF CORTICOSTEROIDADMINISTRATION IN OPTIC NEURITIS

Determination of the optimal timing of corticoste-roid treatment in optic neuritis has been elusive.The ONTT addressed the effect of i.v. and oralsteroids within 8 days of symptom onset, and theeffects of more acute or delayed treatment of opticneuritis with corticosteroids are not fully known.Treatment of optic neuritis with corticosteroidsduring the presumed hyperacute phase was eval-uated in a prospective case series of patients witha history of optic neuritis and recurrence of pain ineither eye [18]. Eight patients were evaluated in thepresumed hyperacute stage of optic neuritis, prior tothe onset of vision loss. Five of the eight patientsunderwent MRI, and all five demonstrated opticnerve enhancement. Treatment with high-dosei.v. steroids was given immediately, and no visionloss occurred in any of the patients, suggesting thatcorticosteroid treatment during the painful phase ofpresumed optic neuritis, before the onset of visionloss, may prevent vision loss.

CORTICOSTEROIDS IN THE TREATMENTOF ATYPICAL OPTIC NEURITIS

Atypical optic neuritis may be differentiated fromtypical optic neuritis by progressive unilateral orbilateral visual loss, poor visual recovery, lack ofeye pain, haemorrhages or exudates on funduscopicexamination, and relapse after steroid withdrawal[19]. Atypical optic neuritis may be a manifestationof neuromyelitis optica (NMO), autoimmune opticneuropathy, chronic relapsing inflammatory opticneuropathy (CRION), neuroretinitis or optic neuro-pathy associated with systemic diseases such as con-nective tissue diseases, vasculitides or sarcoidosis.Although data from prospective randomized clinicaltreatment trials do not exist for corticosteroids foratypical optic neuritis, retrospective case series andexpert opinion suggest that visual outcomes may bepoor if left untreated [1

&

], and high-dose IVCS areoften the preferred treatment.

Optic neuritis associated with NMO is typicallytreated with high-dose IVCS, a practice adoptedfrom the treatment of idiopathic optic neuritis,despite the lack of a clinical trial evaluating its



efficacy specifically in NMO [20]. The efficacy ofhigh-dose IVCS (IVCS) was recently evaluated incomparison with plasma exchange (PLEX) alongwith IVCS in acute NMO relapses [21

&

]. This non-randomized retrospective study found that disabil-ity scale scores were more likely to be at or belowtheir baseline in the PLEX along with IVCS groupthan in the IVCS alone group at 6–18 monthsfollow-up. Despite relapses of NMO being lessresponsive to high-dose corticosteroids than relap-ses of multiple sclerosis [21

&

], high-dose IVCS areconsidered standard therapy in the treatment ofNMO relapses.

Patients with autoimmune optic neuritis, whichhas included patients with laboratory evidence of asystemic collagen vascular disease, in one seriesresponded very favourably and often dramaticallyto high-dose corticosteroids [22]. In a retrospectivecase series of 15 patients considered to have CRION,which is considered to differ from typical opticneuritis by its steroid-dependent and relapsingcourse, all were described as having a ‘clear andprompt response to treatment with systemic cortico-steroids’ [23]. High-dose i.v. or oral corticosteroidsare considered as part of the treatment guidelines forrecurrent neuroretinitis, which typically presentswith optic disc oedema followed by an exudativemaculopathy (‘macular star’) [24]. Infectious causesof optic neuritis are rare, but may include syphilis,Lyme disease, tuberculosis, West Nile virus andothers [25]. There are no clinical trial data on theeffect of corticosteroids in infectious optic neuritis.High-dose corticosteroids are considered a first-linetreatment for most forms of atypical optic neuritis.

CORTICOSTEROIDS IN PAEDIATRIC OPTICNEURITIS

Unlike in adult optic neuritis, paediatric optic neu-ritis most often presents with funduscopic abnor-malities, including optic disc oedema and retinalexudates. A greater proportion of patients withsevere and/or bilateral vision loss is also a charac-teristic of paediatric optic neuritis [26,27]. Childrenwith optic neuritis tend to recover faster than adultsand a higher percentage involve secondary causesthan in adults [28

&

]. Despite the lack of prospectiveclinical data in children to support its use, high-dosei.v. methylprednisolone is considered first-linetreatment for paediatric optic neuritis by extensionfrom the ONTT, as affected children often presentwith impairment of visual acuity severe enough tojustify its use. Following IVCS, a prolonged oralcorticosteroid taper over 2–6 weeks is common, assome experts believe that there is an increased rateof relapse with early cessation of corticosteroids



Factors that maydecrease the

risk: benefit ratio

Higher potential forbenefit

Onset < 8 days

White matter lesionson brain MRI

Significant pain

Significant vision impairment

Features of atypical optic neuritis

Higher potential foradverse reaction

History of poorlycontrolled diabetes

History of adversereaction to steroids

Potential for significant harmfrom common steroid side effects

Factors that mayincrease the

risk: benefit ratio

FIGURE 2. Weighing the potential risks and benefits of high-dose intravenous corticosteroid treatment of acute optic neuritis.High-dose corticosteroids are most likely to be helpful in patients with optic neuritis with significant vision loss, significant pain,acute symptom onset (<8 days), T2 hyperintense white matter lesions on brain MRI or features of atypical optic neuritis. Theclinician must weigh the potential for benefit against possible adverse effects before making a treatment recommendation. Costand availability of treatment may not directly impact the risk:benefit ratio, but may influence the advisability of treatment.

Should optic neuritis be treated with steroids? Mackay

[27,29,30]. One recent small retrospective study of26 consecutive paediatric patients with optic neu-ritis treated for 3 days with i.v. methylprednisolonecompared those treated with an additional 2 weeksof oral corticosteroids with those treated for morethan 2 additional weeks. Final visual acuity, sideeffects and relapse rates did not differ betweenthe two groups with a mean follow-up of 70 weeks.This study included potential for selection bias withlonger courses of corticosteroids given to patientsexhibiting poor recovery.

FUTURE RESEARCH

Despite an abundance of useful data gathered fromthe ONTT and other clinical trials and case series,important questions remain regarding the use ofcorticosteroids in the treatment of optic neuritis,such as the optimal dose, timing, specific formu-lation and route of administration [31,32] andwhether there may be a subgroup of patients withoptic neuritis in whom high-dose corticosteroidtreatment results in persistent, long-term clinicalimprovement.

A recently published review on the investigationof acute optic neuritis called for consensus in theinvestigation of patients with acute optic neuritisin the context of new imaging, laboratory andelectrophysiological techniques [33

&&

]. Organized

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implementation of new techniques in the evaluationof optic neuritis is likely to lead to meaningful newdata, which could help answer lingering questionsregarding the role of corticosteroids in the treatmentof optic neuritis.

CONCLUSION

Two main benefits are often cited as rationale fortreatment of acute typical optic neuritis with IVCS:hastening of visual recovery and a lower rate ofprogression to clinically definite multiple sclerosis(CDMS) at 2 years, but not at 5 years [3,34]. Thepotential for bias confounding interpretation of thedata suggesting a lower rate of progression to CDMSin the short-term has been raised [15].

As with any treatment, the approach to whetheror not to implement a specific therapy relies on anaccurate understanding of the potential risks andbenefits. The ONTT demonstrated relatively goodtolerability of high-dose i.v. methylprednisolone,although patients should be informed of potentialadverse effects, including sleep disturbances, moodchanges, gastrointestinal upset, facial flushing, psy-chosis and hyperglycemia [35].

After a discussion with the patient regardingpotential risks and benefits, it is reasonable torecommend high-dose IVCS to patients with acuteoptic neuritis with bilateral or significant unilateral


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vision loss, severe pain, T2 hyperintensities on MRIthat predict a higher short-term risk of developmentof CDMS or features of atypical optic neuritis(Fig. 2). High-dose corticosteroids may help preventpoor visual outcomes in atypical optic neuritis, butthe excellent visual prognosis in typical optic neu-ritis coupled with the lack of definitive permanentbenefits of high-dose IVCS make the treatment oftypical optic neuritis optional, but helpful inselected cases characterized by significant visionloss, severe pain and/or T2 white matter hyperin-tensities on brain MRI.

Acknowledgements

None.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

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& of special interest&& of outstanding interest
1.&

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corticosteroids in the treatment of acute optic neuritis. N Engl J Med 1992;326:581–588.

4. Andersson PB, Goodkin DE. Glucocorticosteroid therapy for multiple sclero-sis: a critical review. J Neurol Sci 1998; 160:16–25.

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7. Miller H. Discussion on steroid therapy in neurological disease. Proc R SocMed 1961; 54:571–575.

8. Rawson MD, Liversedge L. Treatment of retrobulbar neuritis with corticotro-phin. Lancet 1969; 2:1044–1046.

9. Spoor TC, Rockwell DL. Treatment of optic neuritis with intravenous mega-dose corticosteroids. Ophthalmology 1988; 95:131–134.

10. Beck RW, Cleary PA, Backlund JC. The course of visual recovery after opticneuritis. Ophthalmology 1994; 101:1771–1778.

11. Gal RL. Visual function more than 10 years after optic neuritis: experience ofthe optic neuritis treatment trial. Am J Ophthalmol 2004; 137:77–83.

12. Johnson LN. The 5-year risk of MS after optic neuritis. Neurology 1998;51:1237–1238.

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Moss HE, Gao W, Balcer LJ, Joslin CE. Association of race/ethnicity withvisual outcomes following acute optic neuritis. JAMA Ophthalmol 2014;132:1–7.

This study reanalysed original data from the ONTT with regard to race/ethnicity andfound that although black patients with optic neuritis present with worse vision,recover more quickly and have a worse final visual outcome, black race/ethnicitydoes not appear to play a role in the response of optic neuritis to corticosteroids.15. Goodin DS. Perils and pitfalls in the interpretation of clinical trials: a reflection

on the recent experience in multiple sclerosis. Neuroepidemiology 1999;18:53–63.

16.&

Du Y, Li J, Zhang Y, et al. Risk factors for idiopathic optic neuritis recurrence.PLoS One 2014; 9:1–5.

A retrospective study suggesting an elevated risk of optic neuritis recurrence inChinese patients treated with intermediate-dose oral corticosteroids, which arebelieved to act via genomic effects, as opposed to high-dose corticosteroids,which act principally via nongenomic effects.17. Sellebjerg F, Nielsen HS, Frederiksen JL, Olesen J. A randomized, controlled

trial of oral high-dose methylprednisolone in acute optic neuritis. Neurology1999; 52:1479–1484.

18. Plant GT, Sibtain N, Thomas D. Hyperacute corticosteroid treatment of opticneuritis at the onset of pain may prevent visual loss: a case series. Mult SclerInt 2011; 2011:1–8.

19. Malik A, Ahmed M, Golnik K. Treatment options for atypical optic neuritis.Indian J Ophthalmol 2014; 62:982.

20. Kowarik MC, Soltys J, Bennett JL. The treatment of neuromyelitis optica.J Neuroophthalmol 2014; 34:70–82.

21.&

Abboud H, Petrak A, Mealy M, et al. Treatment of acute relapses in neuro-myelitis optica: steroids alone versus steroids plus plasma exchange. MultScler J 2015. [Epub ahead of print]

IVCS along with PLEX appear to outperform corticosteroids alone in the treatmentof acute relapses of neuromyelitis optica.22. Kupersmith MJ, Burde RM, Warren F, et al. Autoimmune optic neuropathy:

evaluation and treatment. J Neurol Neurosurg Psychiatry 1988; 51:1381–1386.

23. Kidd D, Burton B, Plant GT, Graham EM. Chronic relapsing inflammatory opticneuropathy (CRION). Brain 2003; 126:276–284.

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This small study suggests no difference in paediatric optic neuritis outcomesbetween patients treated with a 2-week oral steroid taper vs. a greater than 2-weekoral steroid taper after treatment with 3 days of high-dose intravenous corticos-teroids.29. Pula JH, MacDonald CJ. Current options for the treatment of optic neuritis.

Clin Ophthalmol 2012; 6:1211–1223.30. Bonhomme GR, Mitchell EB. Treatment of pediatric optic neuritis. Curr Treat

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role of corticosteroids in the management of acute monosymptomatic opticneuritis. Report of the Quality Standards Subcommittee of the AmericanAcademy of Neurology. Neurology 2000; 54:2039–2044.

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This article highlights recent advancements in the evaluation of the structure andfunction of the visual pathways in optic neuritis patients and proposes standardcare and research protocols likely to help further standardize the future evaluationof optic neuritis.34. Beck RW, Cleary PA, Trobe JD, et al. The effect of corticosteroids for acute

optic neuritis on the subsequent development of multiple sclerosis. N Engl JMed 1993; 329:1764–1769.

35. Clark D, Kebede W, Eggenberger E. Optic neuritis. Neurol Clin 2010; 28:573–580.



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