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Optic Neuritis Treatment of Optic Neuritis Andrzej Grzybowski 1,2 and Martyna Pieniążek 3 1. Head, Department of Ophthalmology, Poznan City Hospital; 2. Chair of Ophthalmology, University of Warmia and Mazury; 3. Resident, Department of Ophthalmology, Wroclaw Medical University, Wroclaw, Poland Abstract Optic neuritis (ON) is a self-limiting condition caused by inflammation-driven demyelination process affecting the optic nerve. Main clinical features are sudden, unilateral worsening of visual acuity, colour vision disturbance, visual field defects and motion-induced ocular pain. Spontaneous recovery appears usually within up to 8 weeks. It is a frequent initial manifestation of multiple sclerosis. Treatment of optic neuritis remains controversial, although many clinical trials have been conducted to establish firm therapeutic guidelines. The most relevant clinical trial is the Optic Neuritis Treatment Trial (ONTT), proving three days’ intravenous methylprednisolone therapy is not able to change the long-term prognosis, however improving visual recovery, what became a therapeutic option in monocular patients, patients with significant visual field loss, as well as those with professional requirements of fast visual recovery. The ONTT showed that 15-year risk of developing multiple sclerosis was 50 % regardless of the treatment regimen. Oral corticosteroids are recommended for treatment of acute optic neuritis. Keywords Optic neuritis, multiple sclerosis, treatment, corticosteroids, Optic Neuritis Treatment Trial, ONTT Disclosure: The authors have no conflicts of interest to declare. Received: 8 October 2012 Accepted: 20 November 2012 Citation: European Ophthalmic Review, 2013;7(1):52–5 Correspondence: Andrzej Grzybowski, Department of Ophthalmology, Poznan City Hospital, 3 Szwajcarska St, 361-285 Pozna ń , Poland. E: Optic neuritis (ON) is an acute inflammatory condition affecting the optic nerve in young adults predominantly. 1–4 It is caused by idiopathic inflammatory demyelination of the optic nerve, although there is also evidence of axonal loss. 4,5 Its incidence amounts to 1–5 per 100,000 per year, being more frequent in Caucasians, countries at high latitudes and in spring. 2,3,4,6 The patient’s complaints include both sudden, unilateral worsening of visual acuity ranging from mild visual disturbance to visual loss and movement induced ocular pain. Substantial female predominance among the patients is noted. ON is found to be a frequent initial manifestation of multiple sclerosis (MS), as up to 50 % of ON cases are likely to progress into MS within 15 years. 1–4 the affected eye, but also can be as minor as blurry vision only. Other frequent clinical characteristics of ON include colour vision disturbance of a non-specific pattern, contrast sensitivity reduction, photopsias, relative afferent pupillary reflex (RAPD) and visual field loss presence. 2,4,9 Pau et al. divided ON into four clinical categories, depending on the anatomic localisation: • • • • retrobulbar neuritis characterised by normal disc appearance; papillitis with swollen optic disc; perineuritis involving mainly the optic nerve sheath with or without optic disc oedema; and neuroretinitis with swollen optic disc and a ‘star figure’ of macular exudates. Diagnostic Criteria ON is a self-limiting condition, progressing over hours to 10 days and spontaneously improving within up to 8 weeks. Such a condition not presenting recovery within 8 weeks should require further investigation and may impose other diagnosis implementation. 4 ON can usually be diagnosed taking only clinical features in to consideration. 2,3 Although, typical ON requires no further laboratory studies visual evoked potentials (VEP) testing, 2,7,4 magnetic resonance imaging (MRI) is recommend for prognostic purposes. 4 It was recently shown that patients with normal VEP and MRI had a 96 % probability of a normal lumbar puncture, thus both tests are suggested in all patients before deciding on a lumbar puncture. 8 The most common presentation is a unilateral, subacute, painful visual loss, which is not associated with any systemic disease or other neurological symptoms. Visual acuity might deteriorate to zero light perception in 52 The two first forms are most commonly associated with MS ON. Retrobulbar neuritis accounts for two-thirds of acute demyelinating ON. Temporal optic disc atrophy as well as other residual clinical findings are often seen after ON resolution. 4 The ON recurrence ratio is described to reach 28 and 35 % at 5- and 10-year follow up respectively. 10,11 Differential diagnosis encompasses hereditary, ischaemic, compressive, toxic and other inflammatory optic neuropathies. 3 Treatment Trials In the decades since its first clinical implementation in the 1950s, corticosteroids proved useful in dealing with ON as well as MS. 12 Many clinical trials have been conducted to establish an optimal therapeutic regimen and asses treatment efficacy and its indications. 1,7,9,10,12–22 The trial including greatest number of patients, which became leading treatment guideline, was the Optic Neuritis Treatment Trial (ONTT), carried out in 1988–2006. 1,2,9–12,15,18 © Touch ME dical ME dia 2013