Why Therapeutic Compliance in Optic Neuritis Deserves to Be More Than Just a Footnote - Response

Letters to the Editor compounded where the regimen is onerous as would be the case with prednisone tablets. As Dr. Morrow explained "prednisone in 20-mg tablet form is generally the most available and least expensive alternative in the United States." A prescription of oral prednisone 1,250 mg (equaling methylprednisolone 1,000 mg) for 3 days would require a patient to take more than sixty 20-mg tablets in a day, which may prove too much for some patients. Methylprednisolone (at least in Europe) comes in 100-mg tablet form, and patients will no doubt find taking 10 tablets more palatable than taking 60. The acceptability to patients of a proposed treatment is vital in the case of demyelinative optic neuritis, where noncompliance with oral corticosteroids resulting in a patient taking lower doses will not only have no benefit but may even cause harm. In view of this, we would like to strongly encourage everyone prescribing oral treatment for optic neuritis to emphasize the importance of full compliance, and, where this seems unlikely at the outset, offer treatment with IV-MP, or avoid steroids altogether. Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland James M. A. Ellison, BMedSci(Hons), BMBS, PGDip, MRCPsych Medical Education Unit, University of Nottingham School of Medicine, Nottingham, United Kingdom Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, United Kingdom Jessica R. Chang, MD Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland USC Roski Eye Institute, Keck Medicine of USC, Los Angeles, California The authors report no conflicts of interest. REFERENCES Anna M. Gruener, BMedSci(Hons), BMBS, MSc, FRCOphth Department of Ophthalmology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom Why Therapeutic Compliance in Optic Neuritis Deserves to Be More Than Just a Footnote: Response I appreciate the comments of Dr. Gruener et al regarding oral steroid administration for optic neuritis (1). I certainly agree that compliance with a full course of therapy should be encouraged; medications are of no value unless a patient takes them. It is every physician's duty to carefully explain benefits and risks of any therapeutic undertaking. Fortunately, published data and personal experience indicate good compliance with a regimen similar to the one I suggested for optic neuritis. Sarah Morrow et al (2) surveyed patients treated with oral prednisone 1,250 mg daily for 5 days for multiple sclerosis relapse, identifying a compliance rate of at least 94%. Protocol deviations for noncompliance were rare in the similarly-dosed COPOUSEP study (3). Dr. Gruener et al expressed reasonable concern over the number of pills needed to deliver the suggested dose of prednisone (1,250 mg daily). Although I noted that 20-mg tablets are the most easily obtained, 50-mg tablets Letters to the Editor: J Neuro-Ophthalmol 2018; 38: 419-425 1. Morrow MJ, Ko MW. Should oral corticosteroids be used to treat demyelinating optic neuritis? J Neuroophthalmol. 2017;37:444-450. 2. Haynes RB, McDonald HP, Garg AX. Helping patients follow prescribed treatment: clinical applications. JAMA. 2002;288:2880-2883. were available at all large Los Angeles-area pharmacies I contacted in a telephone survey in response to this question. Cost for a 3-day course ranged from $33 to 55 if paying out of pocket, and even less with insurance. Another option is mixing the powdered intravenous preparation of methylprednisolone (MP) into a beverage and having the patient drink it as a slurry. This form of MP comes in 1000-mg vials, but is generally available only from inpatient pharmacies. Either way, one might note that these are uncommon steroid-dosing regimens; prescribers should be prepared to answer questions from incredulous pharmacists. There are certainly instances in which intravenous steroid administration might be preferred, including previous intolerance of oral dosing and noncompliance despite thoughtful discussion. There are also occasions when inpatient admission is necessary for management of severe diabetes exacerbation and other acute steroid complications, or for nursing needs of disabled patients. In my opinion, these much more costly interventions should be weighed carefully in view of the prevailing information on high-dose oral steroids. 423 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Letters to the Editor Mark Morrow, MD Department of Neurology, Harbor-UCLA Medical Center, Torrance, California The author reports no conflicts of interest. REFERENCES 1. Morrow MJ, Ko MW. Should oral corticosteroids be used to treat demyelinating optic neuritis? J Neuroophthalmol. 2017;37:444-450. Conservative Treatment for Penetrating Injuries Involving the Cavernous Sinus A n interesting case recently was published of a traumatic needlefish jaw puncture wound that penetrated the medial orbit and entered the cavernous sinus (1). The patient underwent foreign body removal and was administered systemic antibiotics. No further treatment or medication was provided and the patient recovered from his injury. We present a similar case of a penetrating injury of the cavernous sinus that resolved completely with conservative management. A 74-year-old man sustained injury after a longhorn hit him directly in the left eyelid with the horn positioned parallel to the plane of the eye. Examination of the left eye revealed complete ptosis, moderate periorbital ecchymosis and edema, and total ophthalmoplegia. There was a 1-cm laceration of the nasal upper eyelid with fat prolapse. Visual acuity, intraocular pressure, pupillary reactions, and fundus examination were normal with no evidence of injury to the globe. Exploration of the eyelid laceration revealed no foreign body. The wound was irrigated with bacitracin solution and the laceration was repaired. The patient was admitted for 24-hour observation with intravenous antibiotics. Steroids were not prescribed and the patient had complete resolution at 4month follow-up. Although standard treatment guidelines currently do not exist for this rare type of injury (2), steroids are widely used due to their anti-inflammatory effects (3). Surgical intervention is considered when symptoms and signs are refractory to steroids or in the presence of an obvious hematoma, foreign body, or bony compression. Conservative manage- 424 2. Morrow SA, McEwan L, Alikhani K, Hyson C, Kremenchutsky M. MS patients report excellent compliance with oral prednisone for acute relapses. Can J Neurol Sci. 2012;39:352-354. 3. Le Page E, Veillard D, Laplaud DA, Hamonic S, Wardi R, Lebrun C, Zagnoli F, Wiertlewski S, Deburghgraeve V, Coustans M, Edan G; COPOUSEP Investigators, West Network for Excellence in Neuroscience. Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP): a randomized, controlled, double-blind, non-inferiority trial. Lancet. 2015;386:974-981. ment has been implicated in cases of trauma, resulting in complete or partial resolution (4). Our patient and the patient reported by Kum et al (1) support, in select patients, the practice of observation alone for treatment of cavernous sinus syndrome, avoiding potential risks associated with steroid use and surgical intervention. Kimberly Nguyen, BS University of Texas Health Science Center at Houston Medical School, Houston, Texas Ama Sadaka, MD Amina Malik, MD Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas The authors report no conflicts of interest. REFERENCES 1. Kum C, Chang JR, Gruener AM, McCulley TJ. Nonsurgical management of retained needlefish jaw. J Neuroophthalmol. 2018;38:190-191. 2. Chen C, Wang T, Tsay P, Huang F, Lai J, Chen Y. Traumatic superior orbital fissure syndrome: assessment of cranial nerve recovery in 33 cases. Plast Reconstr Surg. 2010;126:205-212. 3. Rai S, Rattan V. Traumatic superior orbital fissure syndrome: review of literature and report of three cases. Natl J Maxillofac Surg. 2012;3:222-225. 4. Fujiwara T, Matsuda K, Kubo T, Tomita K, Yano K, Hosokawa K. Superior orbital fissure syndrome after repair of maxillary and naso-orbito-ethmoid fractures: a case study. J Plat Reconstr Aesthet Surg. 2008;62:e565-e569. Letters to the Editor: J Neuro-Ophthalmol 2018; 38: 419-425 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.