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NEWS IN OPTIC NEURITIS AND MS

References:

1. High-and-Low Risk Profiles for the Development of Multiple Sclerosis Within Ten Years After Optic Neuritis, Archives of Ophthalmic, July 2003.
2. Evidence-Based Eyecare, Jan-Feb 2004 - Commentary by Volpe, N. J., on above-referenced article.
3. MRI Predictors of Early Conversion to Clinically Definite MS in the CHAMPS Placebo Group. Neurology, 2002; 59:998-1005.
4. What To Do When It’s MS. Eyenet, January 2003.
5. Frazzone, H. E., et al. Optic Neuritis: Correlation of Pain and Magnetic Resonance Imaging, Ophthalmology, August 2003.
6. Visual Function More than Ten Years After Optic Neuritis: Experience of the Optic Neuritis Treatment Trial, AJO, January 2004.
7. Arnold, Anthond. Evolving Management of Optic Neuritis and Multiple Sclerosis. AJO, June 2005.

The association between optic neuritis and clinically definite multiple sclerosis (CDMS) continues to become elucidated. Note that MS and CDMS are largely synonymous, however, CDMS refers to more of an absolute/firm diagnosis. These six sources give us clearer guidance for how to evaluate, care for, and estimate risk in the universe of demyelinating disease.

References 1 and 2 show that following an initial episode of optic neuritis, 38% of these patients will go on to develop MS. Now it is important to subdivide those persons having brain lesions on MRI scanning in that they had a 56% risk of developing MS over ten years. If there were no brain lesions, the risk of MS was only 22% within ten years. Interestingly, the number of brain lesions was not clinically relevant. When MS did manifest itself, it usually did so within three years of the initial demyelinating episode. As said above, the ten-year risk for the development of MS overall was 38%, compared to 30% at five years. The rate of MS development decreases after five years. In fact, among patients who had not developed MS at five years, the probability of being diagnosed with MS between five and ten years was 7% in those patients with no MRI lesions, and 27% in those patients with positive MRI scans. Restated, the diagnosis of MS occurs in about three-fourths of patients within the first five years. Previous attacks of optic neuritis or non-specific neurological symptoms (usually transient numbness) increased the risk of MS development from 50% to 70% when the MRI was abnormal. No other demographic or clinical features were predictive of MS. After considering the presence of MRI lesions concurrent with optic neuritisx

Of the patients with optic neuritis and a negative MRI scan, the risk of developing MS was 33% lower for males than females. In this subgroup with negative MRI scans, if there were frank papillitis (as opposed to retrobulbar optic neuritis), the risk of developing MS in such females was halved, and only 1 in 24 of such males developed MS.

In summary, even when the MRI is positive, clinically definite multiple sclerosis (CDMS) does not develop within ten years in more than 40% of patients. If the MRI scan is negative, and the optic neuritis expression is ophthalmoscopically evident (i.e., papillitis - disc edema, hemorrhages, and exudates), the risk of CDMS is very low.

References 2 and 3 looked at CHAMPS (Controlled High-risk Subjects Avonex [beta interferon-1a] Prevention Study) has demonstrated that when Avonex is administered at the time of the first demyelinating event in patients having a positive MRI, the risks of subsequent demyelinating events is roughly halved. Note that all CHAMPS patients received IV corticosteroid prior to starting Avonex. For those CHAMPS patient relegated to the placebo arm, if they had two or more brain lesions, they had a 52% chance of developing CDMS, compared to 24% of patients having fewer than two lesions. Note that this 50% relative risk increase is minimally compatible with the five and ten-year findings discussed per References 1 and 2 above, in that the number of brain lesions carried little clinical significance. Reality is likely a hybrid consensus of these two studies.

Optic Neuritis Treatment Trial Summary
Intensive IV corticosteroid therapy at the time of acute optic neuritis accomplishes two goals: it hastens the recovery of vision, and delays the development of further MS-associated neurological events. Note: Visual outcome at one year is the same, whether or not IV corticosteroid therapy was given at the time of the acute optic neuritis

Reference 5 and 6 speak to pain and visual function.

Why some patients have pain on motion (or other trigeminal pain), and other patients do not have such pain can be partially explained by the qualitative and quantitative degree of optic nerve inflammation. Said differently, just how much inflammation is present in the optic nerve, and especially where the inflamed tissues are relative to the origin attachments of the superior rectus and medial rectus muscles, probably determines the expression of EOM-mediated pain in the presence of optic neuritis.

In the ONTT, about 10% of patients had no eye pain. The lack of pain on movement probably means that the site of optic nerve inflammation is in the canalicular, or intracranial portions of the optic nerve, thus behind where the rectus muscles are attached at the intraorbital optic nerve.

"On average, visual function was worse in patients with MS than those without MS. Recurrent optic neuritis in either eye occurred in 35% of patients. Such attacks were more frequent with MS."

"In most patients, once visual acuity stabilized after the initial episode of optic neuritis (as determined from the visual acuity at one year), it remained remarkably stable for more than ten years."

M&T Commentary:
At ten years, roughly 70% of patients saw 20/20 or better in each eye, and 1% were worse than 20/200 in each eye. We now have a few more pieces of the puzzle. The relationship between optic neuritis and MS is becoming clearer. All in all, the picture is promising. Between the ONTT and CHAMPS, we have therapies that enhance health and vision. Our four-tiered job is not all that challenging:

1. Make the accurate diagnosis of optic neuritis based on history and clinical examination.
2. Order an MRI at the time of optic neuritis diagnosis.
3. Be knowledgeable enough to confidently discuss the various aspects of optic neuritis, visual prognosis, treatment options, and risk of MS with your patients.
4. If the MRI is abnormal, refer that day (or certainly by the next day) to a neurologist to consider IV corticosteroid therapy and subsequent Avonex therapy. If the MRI was normal and the patient wants IV corticosteroid intervention to hasten the recovery of vision, refer to Neurology.