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Optic Neuritis

para>Never use oral prednisone alone as the primary treatment because this may increase the risk for recurrent ON (3)[A].

Pediatric Considerations

  • No systematic study defining high-dose corticosteroids in children with ON have been conducted.
  • Optic disc swelling and bilateral disease are more common in children as is severe loss of visual acuity (20/200 or worse).
  • Consider infectious and postinfectious causes of optic nerve impairment.

ISSUES FOR REFERRAL

Referral to a neurologist and/or ophthalmologist

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Monthly follow-up to monitor visual changes and steroid side effects

PATIENT EDUCATION

  • Provide reassurance about recovery of vision.
  • If the disease is believed to be secondary to demyelinating disease, patient should be informed of the risk of developing MS.
  • For patient education materials favorably reviewed on this topic, contact:National Eye Institute, Information Officer, Department of Health and Human Services, 9000 Rockville Pike, Bethesda, MD 20892, 301-496-5248North American Neuro-Ophthalmology Society (NANOS), 5841 Cedar Lake Road, Suite 204, Minneapolis, MN 55416, 952-646-2037, fax: 952-545-6073, http://www.nanosweb.org/i4a/pages/index.cfm?pageid=3280

PROGNOSIS

  • Orbital pain usually resolves within 1 week.
  • Visual acuityRapid spontaneous improvement at 2 to 3 weeks and continues for several months (may be faster with IV corticosteroids)Often returns to normal or near-normal levels (20/40 or better) within 1 year (90 " 95%), even after near blindness
  • Other visual disturbances (e.g., contrast sensitivity, stereopsis) often persist after acuity returns to normal.
  • Recurrence risk of 35% within 10 years: 14% affected eye, 12% contralateral, 9% bilateral; recurrence is higher in MS patients (48%).
  • ON is associated with an increased risk of developing MS; 35% risk at 7 years, 58% at 15 years (7)[A]:Brain MRI helps to predict risk:0 lesions: 16%1 to 2 lesions: 37%3+ lesions: 51%
  • Poor prognostic factors:Absence of painLow initial visual acuityInvolvement of intracanalicular optic nerve
  • Children with bilateral visual loss have a better prognosis than adults.

COMPLICATIONS

Permanent loss of vision

REFERENCES

11 Vedula SS, Brodney-Folse S, Gal RL, et al. Corticosteroids for treating optic neuritis. Cochrane Database Syst Rev. 2007;(1):CD001430.22 Keltner JL, Johnson CA, Cello KE, et al. Visual field profile of optic neuritis: a final follow-up report from the optic neuritis treatment trial from baseline through 15 years. Arch Ophthalmol. 2010;128(3):330 " 337.33 Simsek I, Erdem H, Pay S, et al. Optic neuritis occurring with anti-tumour necrosis factor alpha therapy. Ann Rheum Dis. 2007;66(9):1255 " 1258.44 Gleicher NB, ed. Principles and Practice of Medical Therapy in Pregnancy. 3rd ed. Norwalk, CT: Appleton & Lange; 1998:1396 " 1399.55 Galetta SL. The controlled high risk Avonex multiple sclerosis trial (CHAMPS Study). J Neuroophthalmol. 2001;21(4):292 " 295.66 Bonhomme GR, Mitchell EB. Treatment of pediatric optic neuritis. Curr Treat Options Neurol. 2012;14(1):93 " 102.77 Optic Neuritis Study Group. Visual function 15 years after optic neuritis: a final follow-up report from the Optic Neuritis Treatment Trial. Ophthalmology. 2008;115(6):1079.e5 " 1082.e5.88 Kaufman DI, Trobe JD, Eggenberger ER, et al. Practice parameter: the role of corticosteroids in the management of acute monosymptomatic optic neuritis. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;54(11):2039 " 2044.99 Arnold AC. Evolving management of optic neuritis and multiple sclerosis. Am J Ophthalmol. 2005;139(6):1101 " 1108.1010 Balcer LJ. Clinical practice. Optic neuritis. N Engl J Med. 2006;354(12):1273 " 1280.

SEE ALSO

Multiple Sclerosis

CODES

ICD10

  • H46.9 Unspecified optic neuritis
  • H46.00 Optic papillitis, unspecified eye
  • H46.10 Retrobulbar neuritis, unspecified eye
  • H46.3 Toxic optic neuropathy
  • H46.13 Retrobulbar neuritis, bilateral
  • H46.2 Nutritional optic neuropathy
  • H46.8 Other optic neuritis
  • H46.12 Retrobulbar neuritis, left eye
  • H46.11 Retrobulbar neuritis, right eye
  • H46.03 Optic papillitis, bilateral
  • H46.01 Optic papillitis, right eye
  • G36.0 Neuromyelitis optica [Devic]
  • H46.02 Optic papillitis, left eye

ICD9

  • 377.30 Optic neuritis, unspecified
  • 377.31 Optic papillitis
  • 377.32 Retrobulbar neuritis (acute)
  • 377.34 Toxic optic neuropathy
  • 341.0 Neuromyelitis optica
  • 377.39 Other optic neuritis

SNOMED

  • 66760008 Optic neuritis (disorder)
  • 73221001 Optic papillitis (disorder)
  • 230507009 Retrobulbar neuritis (disorder)
  • 26125006 Toxic optic neuropathy
  • 25044007 neuromyelitis optica (disorder)

CLINICAL PEARLS

  • MRI is the procedure of choice for determining relative risk and possible therapy for MS prevention.
  • The ONTT showed that high-dose IV methylprednisolone followed by oral prednisone accelerated visual recovery but did not improve the 6-month or 1-year visual outcome compared with placebo, whereas treatment with oral prednisone alone did not improve the outcome and was associated with an increased rate of recurrence of ON (1,2,8)[A],(9)[B],(10)[C].