Optic Neuritis & Multiple Sclerosis

Sixteen patients with acute Optic Neuritis were studied, and randomized into two groups of treatment.

Group I was assigned to in hospital treatment with IntraVenous MethylPrednisolone 500 mg Q8 hours for 10 doses, followed by Oral Prednisone for two weeks and tapering doses thereafter.

Group II was treated with Oral Prednisone one mg per kilogram of body weight for two weeks followed by tapering doses.

All patients had examination of Visual Acuity, Visual Field at baseline and repeated on weeks two, four and sixteen.

Two patients in group I were lost to follow up, and three patients (two in group I and one in group II) had previous established diagnosis of Multiple Sclerosis and the onset of acute Optic Neuritis was considered a recurrence of the disease.

There was no statistical difference between the groups with regards to clinical outcome, Visual Acuity and Visual Field examination (p = 0.329) Fisher test.

The American multicenter study, 'A Randomized, Controlled Trial Of CorticoSteroids In The Treatment Of Acute Optic Neuritis', showed how Retrobulbar Neuritis should not be treated.

Oral Steroids (1 mg per kilogram of body weight per day) are not only ineffective but are also associated with a higher rate of recurrences compared to high dose I.V. MethylPrednisolone.

In the light of this study, 'low-dose' Steroid therapy for RetroBulbar Neuritis is contraindicated.

High-dose MethylPrednisolone speeds up recovery of the visual function and lowers the recurrence rate two years after treatment; however, this protective effect could not be demonstrated after three years.

These recommendations are valid only for Primary DeMyelinating RetroBulbar Neuritis.

Other less common Optic Neuropathies, such as these of MicroVascular origin, respond to 'low-dose' Steroids; therefore, the diagnosis of Primary DeMyelinating RetroBulbar Neuritis must be made with caution as a Diagnosis of Exclusion.

This paper discusses a number of important Optic Neuropathies and gives recommendations for investigations. Compressive Optic Neuropathies and Chiasmal Disease will not be covered here.

The Tubingen study of Optic Neuritis treatment was started in 1980 to apply new and sensitive tests for monitoring a potential therapeutical Steroid effect on the course of Acute Optic Neuritis.

Visual Evoked Potentials were used to assess an effect of Oral MethylPrednisolone in a randomized, controlled trial.

Forty-eight patients with Acute Optic Neuritis were treated orally either with MethylPrednisolone (100 mg per day initially, dosage reduction every 3 days; n = 15) or with Thiamine (100 mg per day; n = 33) in the control group, 36 of them in a double-blind procedure.

A comparison of the two treatment groups indicated that Oral MethylPrednisolone resulted in a faster improvement in Visual Evoked Potential latency in the initial phase (p = 0.015, 4 weeks after onset), but had no benefit after 12 weeks and 12 months.

Follow-up showed different types of courses in the Visual Evoked Potential Latencies.

The Visual Evoked Potential latencies were correlated to other outcome variables, such as Visual Evoked Potential Amplitudes, Visual Acuity, Aulhorn flicker test and Perimetry.

We were able to handle nonmeasurable Latencies in highly pathologic cases by means of ranks (taking into account censored observations).

Optic Neuritis is frequently the first clinical sign of Multiple Sclerosis (MS). Study results indicate that MethylPrednisolone pulse therapy reduces the rate of development of MS over a two year period.

Patients also experience quicker recovery of Vision. This short duration therapy presents immediate and intense nursing care challenges.

Coordination of care between three departments at the Univ of Michigan Medical Center enables many patients to complete IV [IntraVenous] pulse therapy at home.

Although coordination is challenging for providers, ambulatory care and home care benefit patients and their families with potential healthcare cost savings.

Treatment of Acute Optic Neuritis with Steroids has been shown to hasten visual recovery without affecting the final degree of recovery.

However, MRI-clinical studies indicate that patients with long Optic Nerve lesions, particularly those that involve the Nerve within the Optic Canal, may have a worse prognosis for recovery of Vision.

Partly because such lesions could lead to swelling and subsequent ischemic Optic Nerve damage, Steroids could have a selective beneficial effect on this subgroup of patients. The present randomized trial was designed to test this possibility.

Sixty-six patients with Acute Optic Neuritis received IV saline or IV MethylPrednisolone. The clinical, psychophysical, electrophysiologic, and MRI outcomes were assessed after 6 months.

Patients with short lesions presented earlier than those with long lesions (involving three or more 5-mm-thick slices of any part of the Optic Nerve.

As well as its IntraCanalicular portion), and lesion length was significantly less in patients presenting within a week of onset of symptoms.

Lesions also tended to lengthen during follow-up in individual patients. Treatment did not limit lesion length in either the long or short lesion subgroup and had no significant effect on final Visual outcome.

We conclude that Steroids do not improve Visual outcome or lesion length in patients with Acute Optic Neuritis.

Comments:

• Comment in: Neurology 1998 Nov;51(5):1516-7

Twenty five patients with Optic Neuritis (ON) of unknown etiology were treated with a high dosage of IntraVenous Vitamin C.

We measured blood levels of Vitamin A, B1, B2, B6, B12, C, E, Folate and Zinc. All levels were compared with the normal values of our laboratory.

The blood level of Vitamin C (p < 0.001) was significantly less than the mean value of the normal. The blood levels of Vitamin E, B6 (p < 0.01) and Zinc (p < 0.001) also significantly decreased.

IntraVenous administration of Vitamin C was given in those patients with decreased blood level of Vitamin C.

In order to compare the effect on Vision by this treatment, the amplitude of recovery of Vision, the time needed to attain the maximum Vision, and the speed of Visual recovery were analyzed. The results were compared with groups receiving other treatments.

That is, Group A received IntraVenous administration of high dosage of Vitamin C, Group B, IntraVenous pulse administration of CorticoSterone, Group C, oral administration of CorticoSterone, and Group D, oral administration of Vitamin B12.

Vision was significantly improved in all groups. There was no significant difference in improvement of Visual Acuity.

IntraVenous administration of Vitamin C can be evaluated as the method of choice for the treatment of patients with ON. A possible mode of action by Vitamin C on free radicals is discussed.

Traumatic Optic Neuropathy is one of true Ophthalmic emergencies and there is no proven form of treatment for traumatic Optic Neuropathy.

Here we were presented with 30 cases of sudden visual loss following blunt eye trauma seen in Kaohsiung Medical College Hospital, Taiwan from April 1994 to March 1997.

We analyze the treatment style, Visual Acuity, elapsed time since injury and orbit computed tomography retrospectively.

Among them, 21 cases received IntraVenous MethylPrednisolone treatment, 2 cases received Oral Prednisolone.

2 cases underwent Optic Canal decompression in addition to IntraVenous MethylPrednisolone and 5 cases were carefully monitored without any kind of treatment.

Thirteen of the 21 cases (62%) in IntraVenous MethylPrednisolone group got Visual improvement.

Patients with initial Vision better than light perception benefitted more from treatment than did the patients who with no light perception in medical treatment group (85% VS 20%) (p < 0.05).

Thirteen of the 30 cases (53.3%) had Orbit fracture and 2 of the 30 cases (6.7%) had a fracture of the Optic Canal.

These two cases also received Optic Canal decompression surgery in addition to IntraVenous Steroid treatment but the prognosis was poor.

In conclusion, IntraVenous MethylPrednisolone does offer help in traumatic Optic Neuropathy. Whether or not initial Visual Acuity was better than light perception was a key risk factor in the outcome.

In this article, we also compare our results with other series in the literature and found that the value of different treatment in traumatic Optic Neuropathy still needs to be prospectively judged in the future.

The authors reviewed the records of 20 patients with Optic Neuritis, all of whom were diagnosed as having clinically definite Multiple Sclerosis (MS).

They were classified into two subgroups: Group A, consisting of 9 patients who had shown Acute Transverse Myelopathy (ATM); and Group B, 11 patients without ATM.

Four patients (44%) in Group A had complete visual loss, but none in Group B.

Six patients (67%) in Group A had less than 0.1 Visual Acuity in the affected Eye, but only 2 patients (18%) in Group B.

Four patients in Group A showed evidence of AntiCardiolipin AntiBodies.

While both groups were diagnosed as having Clinically Definite MS, there were differences between them in the clinical features.