Acute Management of Optic Neuritis: An Evolving Paradigm

Abstract

The current management of acute optic neuritis (ON) is focused on expediting visual recovery through the use of high-dose intravenous corticosteroids. The recent identification of specific autoantibodies associated with central nervous system inflammatory disorders has provided novel insights into immune targets and mechanisms that impact the prognosis, treatment, and recurrence of ON. Therefore, neurologists and ophthalmologists need to be aware of clinical, laboratory, and imaging findings that may provide important clues to the etiology of ON and the potential need for aggressive management. Moving forward, rapid and accurate diagnosis of inflammatory ON will likely be critical for implementing clinical care that optimizes short-term and long-term therapeutic outcomes.

FIG. 1.

MRI of optic neuritis. A. Postcontrast axial T1 scan with fat suppression shows a longitudinally extensive lesion involving the intraorbital left optic nerve in a patient with optic neuritis and MOG-IgG. B. Postcontrast coronal T1 fat-suppressed image demonstrates prominent optic nerve sheath and nerve enhancement. Axial (C) and coronal (D) T1 views of a lesion involving the right intracranial optic nerve and optic chiasm in a patient with optic neuritis and NMOSD. E. Post-contrast coronal T1 fat-suppressed image reveals enhancement of both optic nerves and surrounding sheaths in a patient with optic neuritis and MOG-IgG. MOG-IgG, myelin oligodendrocyte glycoprotein autoantibodies; NMOSD, neuromyelitis optica spectrum disorder.

FIG. 2.

Flowchart outlining a prospective approach to acute ON treatment. “Recurrent,” repeat event of acute ON in a previously affected eye. “High-dose IVMP,” high-dose intravenous methylprednisolone, subcutaneous/intramuscular adrenocorticotropic hormone, or oral high-dose corticosteroid bioequivalent. “High-dose IVMP + PLEX/IA,” “high-dose IVMP” with plasma exchange/immunoadsorption performed concurrently or within 5 days. “High-dose IVMP or previous Rx,” “high-dose IVMP” or previous successful acute therapy. “Antibiotics,” appropriate antimicrobial or antiviral agent. AQP4, aquaporin-4; IA, immunoadsorption; IVMP, intravenous methylprednisolone; MOG, myelin oligodendrocyte glycoprotein; MS, multiple sclerosis; ON, optic neuritis; PLEX, plasmapheresis.