This handout is for optic neuritis — typical (demyelinating) vs atypical (nmosd/mogad) neuro-ophthalmology lens. Your care team identified this based on: subacute monocular vision loss over hours-days with periocular pain worse on eye movement — the typical demyelinating optic-neuritis presentation (beck ontt nejm 1992 pmid 1734247; petzold lancet neurol 2022 pmid 36179757).
Other reasons your team may use this plan: disproportionate colour-vision loss (red desaturation) + central/cecocentral scotoma in one eye — optic-nerve dysfunction until excluded (beck ontt nejm 1992 pmid 1734247; petzold lancet neurol 2022 pmid 36179757); severe (nlp/cf), bilateral simultaneous, painless, or non-recovering optic neuropathy — atypical: mandates aqp4/mog serology + nmosd/mogad/infectious/granulomatous workup (wingerchuk neurology 2015 pmid 26092914; banwell lancet neurol 2023 pmid 36706773; petzold lancet neurol 2022 pmid 36179757); known ms / nmosd / mogad or recurrent optic neuritis presenting with a new attack — relapse entry; aqp4/mog status reframes acute therapy and dmt (wingerchuk neurology 2015 pmid 26092914; jarius j neuroinflammation 2016 pmid 27793206).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| methylprednisolone | 1000 mg | IV | once daily × 3-5 days | ONTT — Beck NEJM 1992 (PMID 1734247) — IV methylprednisolone speeds visual recovery in the first weeks but the 6-month/1-year acuity is UNCHANGED vs placebo (Beck Arch Ophthalmol 1993 PMID 8512477). Steroid is optional — recovery occurs without it; offered mainly when faster recovery matters functionally. |
| prednisone | CONTRAINDICATED as standalone therapy | PO | do not use alone | ONTT — Beck NEJM 1992 (PMID 1734247) — standalone oral prednisone (1 mg/kg) DOUBLED the rate of recurrent optic neuritis vs placebo and conferred no benefit. Oral prednisone is acceptable ONLY as the post-IVMP taper (Step 2), never as primary therapy. |
Plan: Optic neuritis — ONTT-governed, typical/atypical-stratified (IVMP speeds recovery; oral-prednisone-alone CONTRAINDICATED; PLEX for severe/NMOSD; chronic immunotherapy routed OUT)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
The long-tail deliverable is RISK-STRATIFIED DISEASE-MODIFYING ROUTING: (1) Typical ON + ≥1 MRI lesion → high 15-year MS risk → MS DMT discussion via neuro.multiple-sclerosis.core.v1 (Beck Arch Neurol 2008 PMID 18541792). (2) AQP4-NMOSD → lifelong chronic immunotherapy (rituximab/eculizumab/inebilizumab/satralizumab class — routed) and explicit MS-DMT avoidance via neuro.nmosd-mogad.core.v1 (Wingerchuk Neurology 2015 PMID 26092914). (3) MOGAD relapsing/steroid-dependent → chronic immunotherapy + slow steroid taper via neuro.nmosd-mogad.core.v1 (Banwell Lancet Neurol 2023 PMID 36706773). (4) Reciprocal handoff with ophtho.acute-vision-loss.core.v1 (the upstream triage engine). Low-vision rehabilitation for incomplete recovery; relapse-warning education.
Guideline: Optic Neuritis Treatment Trial (ONTT — Beck et al, NEJM 1992/1993, Arch Ophthalmol 1993, final 15-year MS-risk follow-up Arch Neurol 2008) + Petzold et al, Lancet Neurol 2022 consensus diagnosis & classification of optic neuritis + Wingerchuk et al, Neurology 2015 NMOSD international consensus diagnostic criteria (AQP4-IgG) + Banwell et al, Lancet Neurol 2023 International MOGAD Panel proposed criteria (MOG-IgG) + Weinshenker et al, Ann Neurol 1999 plasma-exchange RCT for steroid-refractory severe CNS demyelinating attacks