Journal of Neuro-Ophthalmology, December 1995, Volume 15, Issue 4

Letter to the Editor

Journal of Neuro- Ophthalmoiogy 15( 4): 261- 263, 1995. © 1995 Lippincott- Raven Publishers, Philadelphia Letter to the Editor Optic Neuritis Treatment Trial To the Editor: I enjoyed the recent editorial about the Optic Neuritis Treatment Trial by Dr. Savino ( 1), and would like to add a few comments. Prior to the publication of the results showing a protective effect of high dose steroids against MS in patient with MRI abnormalities ( 2), life was fairly simple. Those of my optic neuritis patients who wished to have more rapid recovery of vision opted for steroids. I would discuss the data con­cerning the probability of developing MS ( 3), but would actively discourage the patient from further investigations such as MRI for two reasons. First, the results in an otherwise neurologically asymp­tomatic patient were of uncertain clinical signifi­cance. Second, I wished to avoid labeling the pa­tient with a chronic and essentially untreatable dis­ease in the present health care climate, particularly considering the issues surrounding preexisting conditions. I would not document the content of the discussions in the patient's chart, for similar reasons. The new information about the usefulness of MRI in predicting who might benefit from high dose steroids is very exciting. I would agree with Dr. Savino that in an ideal world one would like to obtain an MRI on every patient presenting with optic neuritis, and make a decision about high-dose steroid treatment based upon the MRI re­sults. However, consider the following, increas­ingly typical scenario. Case Presentation A 30- year- old healthy woman presented on March 15,1994, with a 3- day history of pain on eye movements, followed by visual loss OS. Examina­tion OD was normal. Examination OS showed a typical optic neuropathy, with decreased central vision, dyschromatopsia, a large central scotoma, and a relative afferent pupillary defect. There was no proptosis nor any ocular motor abnormalities. Slit lamp and fundus examination were normal. A diagnosis of retrobulbar optic neuritis was made, and issues surrounding the visual and neu­rologic implications of treatment with high dose steroids were discussed at length. The patient elected to undergo steroid therapy for more rapid return of vision, regardless of the results of an MRI scan. Nevertheless I recommended to the patient's primary care physician that an MRI scan be ar­ranged in order to assess whether the steroids might also protect the patient against MS. The patient received methylprednisolone 500 mg b. i. d. I. V. infusion for 3 days as an outpatient. About 1 week after I had first seen the patient, I received a call from the Quality Assurance Nurse at the patient's health plan asking for more infor­mation to evaluate the necessity of an MRI. I ex­plained the recent literature to her and faxed a copy of the relevant article. When I saw the patient on April 12, 1994, visual acuity, visual fields, and color vision had all re­turned to normal. Approval had still not been ob­tained for an MRI ( and I doubt at this stage that it will be). Although the approach put forward by Dr. Savino is " medically correct," I fear that we will, de facto, be forced to take a different tack. As much as I dislike nonmedical constraints on our patient management, the realities are difficult to escape: 1. We will find, as I have done already, that the health carriers may not approve an MRI in this situation, and, if they do, the approval will often be delayed. In either case a decision about steroids will need to be made independent of the MRI out­come. 2. It will not take long for " cost- effectiveness" to raise its ubiquitous head. Where I practice, the cost of fee- for- service bid outpatient steroids is about $ 1,230.00 ( qd steroids are even cheaper, at about $ 825.00), whereas the cost of a brain MRI with con­trast is $ 1,410.00. Obviously, it is cheaper to give steroids to every patient who presents with optic neuritis, than to give every patient an MRI and a further subgroup steroids. The fact that many neuro- ophthalmologists have now abandoned in­patient q. i. d. steroids, even though this was the only regimen tested by the ONTT, is evidence that our day- to- day management of these patients is already being influenced by factors other than hard medical data. 3. Patients with optic neuritis come from a young mobile section of the population, with a high probability of changing employment and health insurance over any given period. At this point the Clinton health plan, with its promise to rid our vocabulary of the term " preexisting condi­tion," is still a glint in the administration's eye. One should therefore still consider the implica­tions of placing evidence of a possible chronic, es- 262 LETTERS TO THE EDITOR sentially untreatable and unpredictable disease in the patient's medical record, particularly if the pa­tient currently has no significant clinical problems. It is fruitless to try to explain to insurance compa­nies that having white matter lesions does not nec­essarily mean clinical MS. Having every patient with optic neuritis undergo an MRI might result in a group who finds itself virtually uninsurable. Because of these issues I am finding myself more and more frequently recommending high- dose ste­roids to all patients with significant visual loss from optic neuritis, to " hasten the recovery of vi­sion." I discuss the MS issue, informing the pa­tient that a subgroup has been found in whom the treatment seems to protect against clinical MS. I then give the patient the option of having a MRI, discussing some of the nonmedical issues, and knowing full well that, even if the patient elects to have neuroimaging, it will probably be approved belatedly or not at all. I take some comfort in the fact that at least this " shotgun" approach is safe, since high- dose ste­roids pose very little risk in these young healthy patients, and that at least some of my patients ( which ones??!) might be protected from clinical MS. It is certainly less than ideal however, that Dr. Savino's simple management algorithm, based on good data, is subject at present to so much distor­tion by nonmedical realities. Leah Levi, M. B. B. S. Department of Ophthalmology Department of Neurosciences University of California, San Diego La Jolla, CA 92093 REFERENCES 1. Savino PJ. Optic neuritis treatment trial: an editorial. / Clin Neuro- ophthalmol 1994; 14: 55- 7. 2. Beck RW, Cleary PA, Trobe JD, et al. The effect of cortico­steroids for acute optic neuritis on the subsequent devel­opment of multiple sclerosis. N Engl J Med 1993; 329: 1764- 9. 3. Rizzo JF, Lessell S. Risk of developing multiple sclerosis after uncomplicated optic neuritis: a long term prospective study. Neurology 1988; 38: 185- 90. Editorial Comment to " Optic Neuritis Treatment Trial" The letter of Dr. Leah Levi concerning the di­lemma now facing the clinician attempting to man­age a patient presenting with the first attack of optic neuritis prompted the following comments. Having recently attained the Emeritus rank at Bas-com Palmer, I thought I might simply not respond to the problem, but because this problem is of such magnitude in the practice of neuro- ophthalmol-ogy, perhaps the reader will be patient with me as I express my own personal approach and thoughts about this problem. First, let us briefly look at the initiation of the Optic Neuritis Treatment Trial. At the outset, I was invited to participate in the study, but my personal experience with the use of steroids in patients with optic neuritis had convinced me that of three things: ( 1) there are many types of optic neuritis and it is not a single disease entity by any means, ( 2) I believe that experience has shown me that in certain types of optic neuritis, which could be identified by a careful history and office examina­tion, the use of steroids was definitely helpful to the patient, and ( 3) I therefore felt I could not par­ticipate in a study in which patients were going to be differentiated into treatment versus control groups, because I could not elect to manage a pa­tient as a control ( i. e., withhold steroid therapy) in a circumstance where I felt this therapy would def­initely be helpful. I therefore declined to partici­pate in the study. At least one other neuro-ophthalmologist I know told me the same thing, and therefore it should be understood that at least some clinicians felt that steroids given in the proper manner were so helpful that their input was, at their own request, not included in the study. One might say that this was a small number and should not be considered in interpreting the results, but I am simply pointing this out as a mat­ter of record. Finally, after completion of the Optic Neuritis treatment trial, the major conclusions as I under­stand them were as follows: ( 1) Oral steroids in a dose of about 70 mg/ day for 2 weeks not only did not show any definite helpful effect in acute optic neuritis but were subsequently thought to be as­sociated with an increased incidence of later devel­oping multiple sclerosis. This conclusion threw a huge wet blanket across ophthalmology, so much so that many clinicians who wanted to treat pa­tients with optic neuritis with steroids, even under severe circumstances, were afraid to do so. ( 2) However, the trial also showed that intravenous megadose steroids, in a dose of at least 1,000 mg/ day for 3 days, followed by an oral dose taper to 2 weeks showed not only more rapid resolution of the visual deficit early on, but later was reported to have decreased the incidence of subsequently de­veloping multiple sclerosis. The latter point was discussed in detail in Dr. Levi's letter. Now, it would seem to me that logic would cause one to come to certain conclusions from the above data. First of all, steroids are well known to have excellent bioavailability when given by mouth so that there is no significant difference in / Neuro- Ophthalmol, Vol. 15, No. 4, 1995 [CLontt]