New directions in optic neuritis and multiple sclerosis

Severe Bilateral Optic Neuritis: A Rare Presentation of Clinically Isolated Syndrome

Multiple sclerosis (MS) is a disabling disease involving the myelin sheath of neurons in the brain and spinal cord. Optic neuritis (ON) is one of the common presentations of MS, and it typically presents as acute unilateral ON. In the absence of a prior history of MS, the first episode of clinically determined acute ON is considered as a clinically isolated syndrome (CIS). CIS presenting with bilateral acute ON resulting in complete vision loss is very rare. We present a case of a young female patient who presented with bilateral progressive vision loss and was ultimately found to have ON in the absence of a prior history of MS. Important differentials were ruled out. Significant improvement was observed in the patient with high doses of intravenous methylprednisolone. As compared to oral prednisone, intravenous steroids have been shown to be more effective in the treatment of ON in the Optic Neuritis Treatment Trial.

Hyperacute corticosteroid treatment of optic neuritis at the onset of pain may prevent visual loss: a case series

Aim. To show that high-dose corticosteroids may prevent visual loss in patients with optic neuritis (ON) treated at the prodromal, hyperacute, phase of retrobulbar pain. Method. Prospective case series: patients were recruited with a history of ON associated with pain. The patients were advised to report immediately to the investigators should the pain recur in either eye. Where possible, orbital magnetic resonance imaging (MRI) was performed to confirm a recurrence of ON and treatment with high-dose corticosteroids was commenced. Visual function and the patient's subjective account were monitored. Results. Eight patients (including cases of MS, CRION and NMO) presented in the hyperacute phase. MRI confirmed optic nerve inflammation in 5/5. Treatment was commenced immediately, and, in all cases, no visual loss ensued. Conclusion. MRI can be used to confirm acute optic neuritis prior to visual loss in the hyperacute phase. We suggest that treatment with high-dose corticosteroids may abort the attack and prevent loss of vision in patients with ON who are treated at the onset of pain. This has potential implications for the management of acute ON and also for our understanding of the pathogenesis and potential therapeutic targets in the neuroinflammatory conditions associated with ON.

High-dose cyclophosphamide in the treatment of multiple sclerosis

High dose cyclophosphamide (HDC) has been successfully used for the treatment of a variety of autoimmune diseases. In this study, we sought to determine whether the use of high dose cyclophosphamide provided stabilization of relapsing remitting MS (RRMS), secondary progressive MS (SPMS), or primary progressive MS (PPMS). The parameters evaluated were EDSS scores, lesion load and brain volumes by MRI and frequency of relapses. Twenty-three patients underwent immunoablative therapy with HDC and were followed for 3.5 years. Nine were relapsing remitting (RRMS), 11 secondary progressive (SPMS), and 3 primary progressive (PPMS). Four of 9 RRMS have had no clinical progression up to 3.5 years following treatment. Three of 9 patients maintained a normal neurologic examination with improved EDSS scores. Seven of the nine RRMS patients had reduction in flare frequency which was maintained for 3.5 years following treatment or no immunomodulating agents. Subgroup analysis in the RRMS patients of lesion load and brain parenchymal volume revealed a favorable trend in these parameters which did not reach statistical significance. The treatment was generally ineffective for SPMS and failed in the 2 PPMS patients. HDC was well tolerated, demonstrated a good safety profile and had minimal adverse effects. These results along with previous reports suggest that early use of HDC therapy in RRMS is promising.