Key takeaways:
- One doctor stated intravenous corticosteroids are helpful for treating optic neuritis.
- One other argued corticosteroids might enhance the chance for an infection in some circumstances.
SEVILLE, Spain — Remedy of optic neuritis with corticosteroids, findings from the Optic Neuritis Remedy Trial and the validity of earlier therapy paradigms have been debated on the Congress on Controversies in Ophthalmology.
For
Do all sufferers with acute optic neuritis (ON) require high-dose corticosteroids? The reply is sure, in keeping with Andrew G. Lee, MD.
Remedy of optic neuritis with corticosteroids, findings from the Optic Neuritis Remedy Trial and the validity of earlier therapy paradigms have been debated on the COPHy assembly. Picture: Adobe Inventory
The Optic Neuritis Remedy Trial (ONTT) dates again to 1992 and was primarily based on the information of the illness that was accessible at the moment. The invention of particular antibodies related to inflammatory issues of the central nervous methods has altered the general image of ON and its mechanisms, prognosis and therapy.
Andrew G. Lee
“You have to know that optic neuritis has modified. … Now there are two dangerous guys you have to fear about. One man’s identify is MOG, myelin oligodendrocyte glycoprotein, and the opposite man’s identify is NMOSD, neuromyelitis optica spectrum dysfunction,” Lee stated.
In mild of those new findings, a few of the suggestions (“the little white lies,” as Lee referred to as them) of the ONTT have turn into out of date.
“No. 1 is that optic neuritis all the time will get higher. That’s not true anymore. Optic neuritis normally will get higher, and the demyelinating and idiopathic types do get higher, however the dangerous guys, MOG and NMO, want steroids,” Lee stated.
In response to the ONTT, IV steroids solely assist to hurry up the restoration course of that may happen naturally, no matter therapy. This conclusion, Lee stated, was flawed.
“Within the ONTT, we solely did MRI of the mind with no distinction, no orbit, no gadolinium, no fats suppression. You can’t do this anymore. You want MRI of the pinnacle and orbit, gadolinium and fats suppression to see the extent of the enhancement and whether or not the enhancement is within the sheath or within the again,” he stated.
Within the trial, a traditional MRI scan was excellent news as a result of it excluded the analysis of a number of sclerosis (MS). Nonetheless, it’s now identified {that a} regular MRI scan, or a scan that exhibits lesions that aren’t typical for MS, may point out that “the ugly antibody, NMOSD, and MOG, the dangerous, may be lurking in there.”
Lee added that, in keeping with the trial, no laboratory testing was wanted, akin to syphilis serology and antimitochondrial antibody, and neither was a lumbar puncture. That is not true as a result of these assessments could also be related within the context of MOG-associated illness and NMOSD.
The geography of MS may give necessary diagnostic insights. Lee confirmed that within the equatorial areas of each the Northern and Southern Hemisphere, MS is considerably much less prevalent.
“When it’s a Black, Afro Caribbean or African American individual or someone from these areas, you need to be occupied with a non-MS-related optic neuritis,” he stated.
The charges of NMOSD, as he confirmed in one other map, are considerably greater in these populations.
Optic neuritis wants immediate therapy, significantly when associated to NMOSD and MOG, Lee stated. A delay of even 4 days reduces the possibility of regaining 20/20 imaginative and prescient by an element of eight. Remedy, he stated, ought to be intravenous, whereas oral steroids would have the impact of “poking the bear.”
“The bear’s identify is antibody-mediated NMOSD and MOG. … Don’t give oral steroids — that’s poking the bear,” he stated.
NMOSD is misdiagnosed as MS in 50% of circumstances, and this can be a concern as a result of pressing analysis and therapy make a distinction in NMOSD, Lee stated. If not handled promptly, inside 10 months a relapse will happen in half of circumstances, and inside 25 months, 80% of sufferers will progress to transverse myelitis, which may result in paralysis, blindness and dying.
In opposition to
Dan Milea, MD, PhD, agreed with Lee’s level that top doses of IV steroids are helpful typically of optic neuritis. Most, however not all, “as a result of as Andy stated, there’s the dangerous and the ugly, however there may be someone else within the sport: the dangerous, the ugly and the horrible,” Milea stated. “The horrible is an infection, and steroids on an an infection are usually not good.”
Dan Milea
He described the case of a 27-year-old affected person with bilateral, painless, quickly progressing imaginative and prescient loss and questionable optic disc swelling. The affected person was handled with steroids, and imaginative and prescient decreased additional. OCT confirmed he had central serous retinopathy induced by steroids.
“It’s an distinctive case after 3 days to have central serous attributable to steroids, but it surely has been described. And guess what? Did this assist him? Not likely as a result of the analysis was not even optic neuritis, and the affected person didn’t enhance however received worse. The ultimate analysis was Leber’s hereditary optic neuropathy, and we all know that 30% of sufferers with Leber’s neuropathy get steroids for nothing or simply for an encounter with the horrible,” Milea stated.
Toxoplasmosis is one other entity that’s not normally investigated up-front as a result of it’s not a standard reason behind optic neuritis, “however the Jensen’s visible subject defect may put you on the observe,” he stated. Steroids are usually not ideally suited when coping with toxoplasmosis.
For all the great causes defined by Lee, there’s a present shift towards steroids for optic neuritis, but it surely ought to by no means be “all the time,” Milea stated.
“Bear in mind, steroids might be dangerous and may enhance the chance of an infection, central serous retinopathy and extra,” he stated.
References:
- Beck RW, et al. N Engl J Med. 1992;doi:10.1056/NEJM199202273260901.
- Beekman J, et al. Neurol Neuroimmunol Neuroinflamm. 2019;doi:10.1212/NXI.0000000000000580.
- Huda S, et al. Clin Med (Lond). 2019;doi:10.7861/clinmedicine.19-2-169.
- Jarius S, et al. J Neurol. 2023;doi:10.1007/s00415-023-11634-0.
- Matiello M, et al. Neurology. 2008;doi:10.1212/01.wnl.0000303817.82134.da.
- Smith AD, et al. Mult Scler Relat Disord. 2023;doi:10.1016/j.msard.2023.104498.
- Stiebel-Kalish H, et al. Neurol Neuroimmunol Neuroinflamm. 2019;doi:10.1212/NXI.0000000000000572.
- Weinshenker BG, et al. Ann Neurol. 2006;doi:10.1002/ana.20770.
- Zoric L, et al. Medicina (Kaunas). 2024;doi:10.3390/medicina61010007.
Sources/Disclosures
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Lee AG, et al. Debate 1: All acute ON sufferers require excessive dose corticosteroids. Introduced at: Congress on Controversies in Ophthalmology; April 4-5, 2025; Seville, Spain.
Disclosures:
Lee stories consulting for Alexion, Amgen/Horizon, AstraZeneca, Bristol Myers Squibb, Catalyst, Dompe, Etyreal, Stoke, Viridian. Milea stories being co-editor in chief of Neuro-Ophthalmology.
