Elsevier

The Lancet

Volume 360, Issue 9349, 14 December 2002, Pages 1953-1962
The Lancet

Review
Management of acute optic neuritis

https://doi.org/10.1016/S0140-6736(02)11919-2Get rights and content

Summary

Optic neuritis is a common condition that causes reversible loss of vision. It can be clinically isolated or can arise as one of the manifestations of multiple sclerosis. Occasional cases are due to other causes, and in these instances management can differ radically. The treatment of optic neuritis has been investigated in several trials, the results of which have shown that corticosteroids speed up the recovery of vision without affecting the final visual outcome. Other aspects of management, however, are controversial, and there is uncertainty about when to investigate and when to treat the condition. Here we review the diagnostic features of optic neuritis, its differential diagnosis, and give practical guidance about management of patients. The condition's association with multiple sclerosis will be considered in the light of studies that define the risk for development of multiple sclerosis and with respect to results of trials of disease-modifying drugs in these individuals.

Section snippets

Clinical features

Panel 1 shows the typical presenting symptoms and signs of optic neuritis.9 The condition usually presents as a painful subacute unilateral loss of vision, which progresses over a few days to 2 weeks.10 In 10% of individuals, no pain is reported4, 10 and in the rest, the pain varies in severity, although typically does not interfere with sleep (G T Plant, unpublished). Light flashes (phosphenes or photopsias) might be seen by the patient on eye movement.11 Clearly, subclinical cases are

Differential diagnosis

Panel 2 shows the differential diagnoses of optic neuritis and appropriate tests.9, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 Misdiagnosis of optic neuritis has been reported in clinical trials. Of 457 patients enrolled in the ONTT, three were subsequently diagnosed as having anterior ischaemic optic neuropathy, two had compressive lesions (one ophthalmic artery aneurysm and one pituitary tumour), and two had connective tissue diseases in addition to optic neuritis.4, 43 In a later

Treatment

Several trials have been done to attempt to improve the prognosis of typical optic neuritis with respect to visual outcome. Findings of early, observational studies10 suggested that corticosteroids might be effective, although this view was controversial. Subsequent placebo-controlled trials6, 43, 53, 63 of corticosteroids have been done and are summarised in panel 4. A meta-analysis of these trials showed that corticosteroids reduced the number of patients without clinical improvement at 30

Optic neuritis

In 2000, the Quality Standards Subcommittee of the American Academy of Neurology69 stated that “oral prednisolone in doses of 1 mg/kg/day has no demonstrated efficacy in the recovery of visual function in acute monosymptomatic optic neuritis, and therefore is of no proven value in treating this disorder. Higher dose oral or parenteral methylprednisolone or adrenocorticotrophic hormone [corticotropin] may hasten the speed and degree of recovery of visual function in persons with acute

Optic neuritis and multiple sclerosis

The association between optic neuritis and multiple sclerosis has been apparent for many years.10 Multiple sclerosis is a clinical diagnosis based on the dissemination of lesions of the central nervous system in time and space—ie, the occurrence of a second clinical episode at a different site in the central nervous system. Clinically definite multiple sclerosis can be diagnosed when the episodes are confirmed by a neurologist without supporting investigations.81 The risk of development of

Conclusion

Optic neuritis is a self-limiting condition that can usually be diagnosed on the basis of the clinical picture. Parenteral corticosteroids can help to speed up visual recovery without affecting the long-term prognosis for visual function. An expectant approach to management is therefore reasonable, although if there is suspicion of a different diagnosis or deviation from the expected clinical course then urgent investigations are called for to rule out, in particular, a compressive lesion or a

Search strategy

This review is based on reading of neuro-ophthalmology textbooks and on a search of PubMed for articles on “optic neuritis”. Treatment trials were identified by searching PubMed with the search terms: “treatment of”, “corticosteroids”, and “optic neuritis”. Articles on diseases mentioned as part of the differential diagnosis of optic neuritis were identified by searching PubMed for the appropriate condition. Only articles in English were used. The articles were selected to support the

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