## Optic Neuritis: Acute Management **Key Point:** Acute optic neuritis (papillitis) is inflammation of the optic nerve head and requires high-dose corticosteroids to reduce inflammation and accelerate visual recovery. ### Clinical Presentation of Papillitis - Unilateral vision loss (often central scotoma) - **Pain with eye movements** (hallmark feature) - Disc hyperemia and swelling with blurred margins - Flame hemorrhages at disc border - Delayed visual evoked potentials (VEP) - Often associated with demyelinating disease (MS in 50% of cases) ### Drug of Choice: Intravenous Methylprednisolone **High-Yield:** The Optic Neuritis Treatment Trial (ONTT) established IV methylprednisolone 1 g daily for 3 days followed by oral taper as the standard of care. | Feature | IV Methylprednisolone | Oral Prednisolone | Topical Dexamethasone | |---------|----------------------|-------------------|----------------------| | **Onset** | Rapid (hours) | Slow (days) | Minimal systemic effect | | **Efficacy** | High—accelerates recovery | Lower—slower recovery | Ineffective for optic neuritis | | **MS risk reduction** | Yes—reduces 2-year MS risk | No—may increase MS risk | No | | **Indication** | **First-line acute optic neuritis** | Contraindicated as monotherapy | Not indicated | **Clinical Pearl:** Oral prednisolone alone is **contraindicated** because it may paradoxically increase the risk of recurrent optic neuritis and progression to MS. IV therapy is superior for both symptom relief and long-term outcomes. ### Mechanism - Suppresses T-cell and B-cell mediated inflammation at the optic nerve - Reduces blood-brain barrier permeability - Decreases demyelination-associated edema **Warning:** Do not use topical steroids alone—they do not achieve therapeutic levels in the optic nerve and delay appropriate systemic treatment.
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