13.10  Neuro-Ophthalmology

ONTT [xcix,c]

18-46 years old
Acute unilateral ON
Visual symptoms ≤ 8/7
RAPD and VF defect
No previous ON
No previous steroid treatment
No systemic disease (other than MS) that could account for this presentation

IVMP – accelerates visual recovery, but no long-term VA benefits

po prednisone – may increase number of new attacks

MS risk – Caucasian, young adult, recurrent ON, female, prior history neurological symptoms, brain MRI lesions, spine MRI lesions, CSF oligoclonal bands

ON risk:

  • 50% risk of MS at 15yrs
  • Lesions on MRI = risk 75%
  • No lesions on MRI = risk 25%

1991. The Clinical Profile of Optic Neuritis: Experience of the Optic Neuritis Treatment Trial. Archives of Ophthalmology 109(12) 1673-1678.

Beck, R.W.M.D., Cleary, P.A.M.S., Anderson, M.M.J.P.A.C. et al. 1992. A Randomized, Controlled Trial of Corticosteroids in the Treatment of Acute Optic Neuritis. The New England Journal of Medicine 326(9) 581-588.


Controlled High Risk Avonex MS Prevention Study


10 year results

If 1st episode ON & ≥ 2 MRI lesions, give the ONTT regimen, then IM IFNβ-1a weekly to reduce risk of MS from 50% to 33% at 3 years. If low risk give ONTT regimen

10 year results: 40% reduction in CDMS if treated immediately with Avonex i.e. Early treatment of MS reduces long term morbidity

Galetta, S. 2002. The controlled high risk Avonex multiple sclerosis trial (CHAMPS Study). Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society 21 292-295.

ETOMS [ciii]

Early Treatment of MS

Beta interferon weekly 2 years decrease risk progression to CDMS if given for

  • 1 episode of neurological dysfunction +
  • 1MRI lesion

(beta interferon alternate days also decreased conversion to CDMS)

Comi, G., Filippi, M., Barkhof, F. et al. 2001. Effect of early interferon treatment on conversion to definite multiple sclerosis: a randomised study. Lancet 357(9268) 1576-1582.

IONTS [civ]

International Optic Nerve Trauma Study

IV steroids or surgical decompression does not improve outcome in traumatic optic neuropathy

  • Results limited by small sample size, delay in treatment and a tendency to operate and/or give high dose steroid to patients with very low vision (i.e. NPL) and direct optic nerve injury

Levin, L.A., Beck, R.W., Joseph, M.P. et al. 1999. The treatment of traumatic optic neuropathy: the International Optic Nerve Trauma Study. Ophthalmology 106(7) 1268-1277.

CRASH [cv]

Corticosteroid Randomisation

After Significant Head Injury

Increased all-cause mortality at 30 days with IV methylprednisolone if significant head injury (GCS < 14)

NASCIS [cvi]

National Acute Spinal Cord Injury Study

Spinal cord injury patients with high dose IV methylprednisolone (30mg/kg bolus then infusion) within 8 hours of injury had better motor/sensory outcomes

Young W. NASCIS. National Acute Spinal Cord Injury Study. J Neurotrauma. 1990 Fall;7(3):113-4.

NASCET [cvii]

North American Symptomatic Carotid Endarterectomy Trial

  • Stenosis 70 - 99% and symptomatic = surgery (reduced stroke risk at 2 years from 26% to 9% and major/fatal stroke from 13% to 2.5%)
  • Stenosis 50 - 69% and symptomatic = maybe surgery
  • 100% stenosis = no surgery
  • Antiplatelets and statins

Ferguson GG, Eliasziw M, Barr HW et al. The North American Symptomatic Carotid Endarterectomy Trial. Stroke. 1999 Sep;30(9):1751-8.


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