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Show 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 LETTERS TO THE EDITOR 263 blood or tissue level concentrations when given by mouth as compared to intramuscular or intravenous administration. Therefore, if 70 mg/ day by mouth does no good- whereas 1,000 mg/ day intravenously does- the first conclusion should be not that the difference in outcome is due to different routes of administration but that the difference is more reasonably due to the doseage employed. In other words, 70 mg/ day may be too little, and 1,000 mg/ day may be too much, and the proper doseage could lie somewhere in between. The next conclusion to my mind would be that if a small dose of steroids puts a patient at greater risk for developing multiple sclerosis where a larger dose of steroids reduces the risk for later developing multiple sclerosis, that we are now in the realm whereby one can draw from statistics any conclusion he might desire. It does not appeal to logic to say that a little dab of steroids will do you in, whereas a huge dose will turn the coin upside down with regards to later prognosis. I have found that use of subtenon's steroids ( e. g., giving 1 ml or 40 mg of subtenons aqueous triamcinolone) has been very helpful in many cases of optic neuritis and this has been used in my practice for well over 20 years with no problems of consequence whatever. See: Smith JL, McCrary JA, Bird AC, et al. Subtenon steroid injection for optic neuritis. Trans Am Acad Ophthalmol Otol 1970; 74: 1249- 53. Fortunately, this route of steroid administration was not evaluated in the optic neuritis treatment trial, so that the clinician who desires to employ that route can continue to do so without having to be concerned about " bad press" from a major cooperative study, as it simply has not been evaluated in such a study to date. I use a 3- ml syringe with a # 25 gauge needle V2 in. long and inject 1 ml aqueous Kenalog at the junction of outer and middle thirds of lower lid in exactly the same way as in giving retrobulbar anesthesia, and have found that one injection often will last 2- 6 weeks, and seldom needs to be repeated in these cases. It is very important, of course, to not only take a complete history- was there an antecedent upper respiratory infection a few weeks before onset of the optic neuritis?- and a careful examination- are there any cells in the vitreous on a careful slit lamp examination?- for both of these points favor an inflammatory ( i. e., infectious) pathogenesis to the optic neuritis and are votes against a demyeli-native disease. Certainly, pure papillitis or neu-roretinitis are votes against demyelination, whereas a pure retrobulbar optic neuritis with a normal appearing disc early on is more likely to be followed later by multiple sclerosis in the particular age group under consideration. Finally, I would like to say at least a few words about magnetic resonance imaging and optic neuritis. I personally do not think every patient presenting with an initial attack of clinically typical optic neuritis needs to have an MR scan. This not only relates to the significant expense of MR imaging, but also to the fact that the presence of a few " UBOs" or white matter lesions in these patients is a difficult correlate with the subsequent clinical diagnosis of multiple sclerosis. In other words, some UBOs may be present in individuals who do not have multiple sclerosis, and also some patients who subsequently turn out to have undoubted multiple sclerosis may not show any significant abnormalities on MR scanning early on. Therefore, I am quite in agreement with Dr. Levi that the decision as to whether to obtain an MR scan in the patient with optic neuritis must be individualized by the physician seeing that particular patient. It simply is not fair with the myriad variables seen in patients within the clinical spectrum of optic neuritis to make a hard and fast rule that every patient must or should absolutely not have an MR scan. This is a clinical decision that should be made by the neuro-ophthalmologist seeing that particular case. I believe there will be a place for treating certain patients with optic neuritis with subtenons steroids and also other patients with larger doses of oral steroids than have been customarily employed in the past but doing this as an outpatient while carefully following the patient and only for a few days. For example, giving a patient with a severe loss of vision 200- 300 mg/ day of oral prednisone for 3 days and then seeing the patient again would not be unreasonable in my opinion. If the medicine is going to work, this will usually be evident within 2- 3 days, and if no improvement has been noted in that time, the medicine can usually be simply stopped at that point, without the necessity for the taper needed with more protracted use. I am sure that not everyone will agree with these personal experiences. However, there are some things we have learned by experience that may be worth considering by others and not simply discarding them up front because of one or two studies. I pray that wisdom will prevail in the practice of medicine, and no matter what external forces come against the clinician, a good doctor will still be able to cure sometimes, to relieve often, and to comfort always. J. Lawton Smith, M. D. Editor- in- Chief Emeritus / Neuro- Ophthalmol, Vol. 15, No. 4, 1995 |
