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ophtho.optic-neuritis.core.v1

Optic neuritis — typical (demyelinating) vs atypical (NMOSD/MOGAD) neuro-ophthalmology lens

general_internal_medicineacutesubacuteadultpediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

Frame this as a TYPICAL-vs-ATYPICAL optic-neuritis pivot, not a single disease. Typical = young, unilateral, painful, partial, normal/mildly swollen disc, demyelinating/MS-associated, ONTT-governed. Atypical (severe/NLP, bilateral simultaneous, painless, severe disc swelling/haemorrhage, no recovery, age extremes, recurrent) mandates AQP4/MOG serology + NMOSD/MOGAD/infectious/granulomatous/paraneoplastic workup. The hard guardrail set up here: IVMP speeds recovery but oral prednisone ALONE is contraindicated (ONTT — Beck NEJM 1992 PMID 1734247). Chronic disease ownership is routed OUT by engine_id.

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typical/atypical framing set; ONTT oral-prednisone-alone guardrail foregrounded

Patient inputs (17)

Gadolinium MRI brain + orbits: ON-segment enhancement/length pattern + brain white-matter lesions drive both diagnosis and the ONTT 15-year MS-risk stratification (0 lesions ~25% vs ≥1 lesion ~72% MS at 15 y) and therefore the DMT decision (Beck Arch Neurol 2008 PMID 18541792)

Profound loss (no light perception / hand motions) and/or no recovery at the expected window are atypical — typical ON rarely goes to NLP and usually recovers; severe loss raises AQP4-NMOSD prior and the PLEX threshold (Beck Arch Ophthalmol 1993 PMID 8512477; Weinshenker Ann Neurol 1999 PMID 10589540)

Typical demyelinating ON is 15-50; pediatric skews MOGAD/ADEM; ≥50 with optic neuropathy must exclude arteritic AION/GCA and compressive lesions (atypical age) (Banwell Lancet Neurol 2023 PMID 36706773; Liu Br J Ophthalmol 2018 PMID 30514710)

Prior MS/NMOSD/MOGAD, prior optic neuritis, or systemic autoimmunity changes the pretest priors and the acute therapy (NMOSD → aggressive IVMP ± PLEX; MS → DMT decision) (Wingerchuk Neurology 2015 PMID 26092914; Jarius J Neuroinflammation 2016 PMID 27793206)

Periocular pain worse on eye movement is present in ~92% of typical demyelinating optic neuritis; painless severe loss is an atypical flag favouring AION/NMOSD/compressive (Beck ONTT NEJM 1992 PMID 1734247; Petzold Lancet Neurol 2022 PMID 36179757)

Unilateral favours typical demyelinating; bilateral SIMULTANEOUS severe loss is a strong atypical flag for NMOSD/MOGAD/toxic-nutritional/LHON and changes the workup (Wingerchuk Neurology 2015 PMID 26092914; Banwell Lancet Neurol 2023 PMID 36706773)

A RAPD localises the lesion to the unilateral/asymmetric optic nerve/retina and is the single most useful afferent bedside sign; its ABSENCE in claimed monocular loss argues functional or symmetric-bilateral disease (Petzold Lancet Neurol 2022 PMID 36179757)

Colour-vision loss out of proportion to acuity is a hallmark of optic-nerve dysfunction and helps separate optic neuropathy from maculopathy/functional loss (Beck ONTT NEJM 1992 PMID 1734247)

Normal disc (retrobulbar, ~2/3 of typical ON) vs mild papillitis vs SEVERE swelling with peripapillary haemorrhage/exudate (atypical — favours MOGAD perineuritis, AION, infiltration, papilloedema) reshapes the differential (Petzold Lancet Neurol 2022 PMID 36179757; Liu Br J Ophthalmol 2018 PMID 30514710)

≥50 with new headache / jaw claudication / scalp tenderness / PMR mandates GCA exclusion (empiric steroid before biopsy, route OUT) because arteritic AION mimics ON in the older patient (route to rheum.giant-cell-arteritis.core.v1)

Serum AQP4-IgG (cell-based assay) confirms NMOSD — worse visual prognosis, do NOT use MS DMTs (can worsen NMOSD), needs aggressive acute therapy + chronic immunotherapy (Wingerchuk Neurology 2015 PMID 26092914)

Serum MOG-IgG (cell-based assay) confirms MOGAD — relapsing in ~80% (median time-to-relapse ~5 mo, ARR ~0.92), steroid-responsive but steroid-dependent, distinct chronic immunotherapy (Jarius J Neuroinflammation 2016 PMID 27793206; Banwell Lancet Neurol 2023 PMID 36706773)

CSF (cells, protein, oligoclonal bands, infectious panel) supports MS risk (OCB+) and excludes infectious/granulomatous/neoplastic atypical optic neuropathy (Petzold Lancet Neurol 2022 PMID 36179757)

Syphilis/TB/Lyme/Bartonella/HIV, sarcoidosis, or a cancer history broaden an ATYPICAL optic neuropathy to infectious/granulomatous/paraneoplastic causes that need targeted serology/imaging before steroid (Petzold Lancet Neurol 2022 PMID 36179757)

In the ≥50/atypical patient, ESR + CRP support or argue against arteritic AION/GCA; normal values never override empiric steroid if GCA is suspected (route to rheum.giant-cell-arteritis.core.v1)

NMOSD relapse risk rises postpartum; steroid/PLEX and immunotherapy safety gating is pregnancy-dependent (Wingerchuk Neurology 2015 PMID 26092914)

Renal function for steroid-pulse comorbidity management and contrast-MRI safety in CKD (Inker NEJM 2021 race-free eGFR)

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Severity triggers (8)

8 need judgement
  • informationallife_threateningbilateral_severe_simultaneous_loss_aggressive_therapy
    Bilateral simultaneous or rapidly sequential severe optic neuropathy — NMOSD/MOGAD emergency (Wingerchuk Neurology 2015 PMID 26092914)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninggca_arteritic_aion_mimic_in_older_patient
    Age ≥50 with optic neuropathy + new headache / jaw claudication / scalp tenderness / PMR / ↑ESR/CRP — arteritic AION mimicking optic neuritis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereatypical_features_force_nmosd_mogad_serology_workup
    Severe (NLP/CF), bilateral simultaneous, painless, severe disc swelling with peripapillary haemorrhage, no recovery at the expected window, age extreme, or recurrent — ATYPICAL optic neuritis (Petzold Lancet Neurol 2022 PMID 36179757)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereno_recovery_at_expected_window_reopen_workup
    Failure to begin recovering acuity/colour/fields within the expected window for typical ON despite (or without) IVMP (Beck Arch Ophthalmol 1993 PMID 8512477)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaqp4_nmosd_positive_aggressive_and_avoid_ms_dmt
    Serum AQP4-IgG positive (NMOSD) — worse visual prognosis; MS DMTs can WORSEN disease (Wingerchuk Neurology 2015 PMID 26092914)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinfectious_or_granulomatous_or_paraneoplastic_cause
    Atypical optic neuropathy with infectious (syphilis/TB/Lyme/Bartonella/HIV), granulomatous (sarcoid), or paraneoplastic features — steroid alone may be harmful or insufficient (Petzold Lancet Neurol 2022 PMID 36179757)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatems_conversion_high_risk_mri
    ≥1 demyelinating white-matter lesion on baseline contrast MRI brain — high 15-year MS conversion risk (~72% vs ~25% with 0 lesions) (Beck Arch Neurol 2008 PMID 18541792)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemogad_steroid_dependent_slow_taper
    MOG-IgG positive optic neuritis — steroid-responsive but steroid-dependent; relapse rate high (ARR ~0.92, ~80% multiphasic) (Jarius J Neuroinflammation 2016 PMID 27793206)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives disposition
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Recommended regimen

Optic neuritis — ONTT-governed, typical/atypical-stratified (IVMP speeds recovery; oral-prednisone-alone CONTRAINDICATED; PLEX for severe/NMOSD; chronic immunotherapy routed OUT)
axis: optic_neuritis_ontt_typical_atypical_stratifiedstep 1 - Step 1 — Typical demyelinating ON: IV methylprednisolone (speeds recovery only) — NEVER oral prednisone alone
Selected step "Step 1 — Typical demyelinating ON: IV methylprednisolone (speeds recovery only) — NEVER oral prednisone alone" — Young (15-50) unilateral painful subacute partial vision loss + dyschromatopsia + RAPD + normal/mildly swollen disc; GCA and atypical-cause flags absent
  • methylprednisolone
    first line
    systemic_corticosteroid
    1000 mg • IV • once daily × 3-5 days (max: 1000 mg/day)
    triggers: typical_demyelinating_optic_neuritis, patient_wants_faster_recovery, functionally_disabling_loss
    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.
    rxcui 6902
  • prednisone
    contraindication substitute
    systemic_corticosteroid
    CONTRAINDICATED as standalone therapy • PO • do not use alone (max: n/a)
    triggers: oral_prednisone_alone_must_not_be_used_in_typical_optic_neuritis
    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.
    rxcui 8640

outpatient playbook — drug actions (3)

  1. 1. IV methylprednisolone (typical ON — speeds recovery only)
    rxcui 6902
    1000 mg • IV • once daily × 3-5 d
    trigger: Typical demyelinating ON where faster recovery matters functionally (Beck ONTT NEJM 1992 PMID 1734247)
    Speeds recovery; does NOT change final acuity; optional (recovery occurs without it)
  2. 2. Post-IVMP oral prednisolone TAPER (taper only)
    rxcui 8638
    1 mg/kg then taper ~11-14 d • PO • once daily taper
    trigger: ONLY after an IVMP pulse, per local protocol (Beck ONTT NEJM 1992 PMID 1734247)
    Oral steroid permissible only as the post-IV taper; standalone oral prednisone is contraindicated (↑recurrence)
  3. 3. Oral prednisone ALONE — DO NOT PRESCRIBE
    contraindicated • PO • never as standalone
    trigger: Guardrail: standalone oral prednisone doubled recurrence vs placebo in ONTT (Beck NEJM 1992 PMID 1734247)
    Hard ONTT contraindication — the single most important prescribing error to avoid in optic neuritis

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Optic neuritis — typical (demyelinating) vs atypical (NMOSD/MOGAD) neuro-ophthalmology lens** (ophtho.optic-neuritis.core.v1).
Phenotype framing: Terminal differential with named pivot findings: TYPICAL demyelinating ON (young + unilateral + pain-on-movement + dyschromatopsia + RAPD + normal/mild disc + good recovery pivot) vs AQP4-NMOSD ON (severe/NLP + bilateral/recurrent + long posterior/chiasmal enhancement + AQP4-IgG+ + poor recovery pivot) vs MOGAD ON (severe but recovers + bilateral + SEVERE disc swelling/perineural enhancement + MOG-IgG+ + steroid-responsive/steroid-dependent + pediatric pivot) vs arteritic AION/GCA (≥50 + pallid disc edema + jaw claudication + ↑ESR/CRP/platelets pivot — route to rheum.giant-cell-arteritis.core.v1) vs non-arteritic AION (sudden painless + altitudinal field + small crowded "disc at risk" + vasculopath + normal ESR pivot) vs papilloedema (BILATERAL disc swelling + preserved acuity early + headache/pulsatile tinnitus + raised ICP pivot) vs CRAO/CRVO (retinal not optic-nerve fundus signs pivot — route to ophtho.acute-vision-loss.core.v1) vs compressive optic neuropathy (slowly progressive painless + optociliary shunt/proptosis + mass on MRI pivot) vs toxic/nutritional (bilateral painless symmetric + cecocentral + B12/folate/ethambutol/methanol pivot) vs LHON (young male + bilateral sequential painless + telangiectatic disc + mtDNA pivot) vs functional (normal RAPD/fundus/OCT/VEP + non-physiologic fields pivot — diagnosis of exclusion).
Scope: Frame this as a TYPICAL-vs-ATYPICAL optic-neuritis pivot, not a single disease. Typical = young, unilateral, painful, partial, normal/mildly swollen disc, demyelinating/MS-associated, ONTT-governed. Atypical (severe/NLP, bilateral simultaneous, painless, severe disc swelling/haemorrhage, no recovery, age extremes, recurrent) mandates AQP4/MOG serology + NMOSD/MOGAD/infectious/granulomatous/paraneoplastic workup. The hard guardrail set up here: IVMP speeds recovery but oral prednisone ALONE is contraindicated (ONTT — Beck NEJM 1992 PMID 1734247). Chronic disease ownership is routed OUT by engine_id.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Optic neuritis — ONTT-governed, typical/atypical-stratified (IVMP speeds recovery; oral-prednisone-alone CONTRAINDICATED; PLEX for severe/NMOSD; chronic immunotherapy routed OUT)** — step "Step 1 — Typical demyelinating ON: IV methylprednisolone (speeds recovery only) — NEVER oral prednisone alone".
1. methylprednisolone 1000 mg IV once daily × 3-5 days (systemic_corticosteroid, first line) — 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.
2. prednisone CONTRAINDICATED as standalone therapy PO do not use alone (systemic_corticosteroid, contraindication substitute) — 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.

Setting playbook (outpatient) — Confirm optic neuritis, resolve the TYPICAL-vs-ATYPICAL pivot, arrange urgent contrast MRI brain/orbits for MS-risk stratification, offer (do not mandate) IVMP to speed recovery, and NEVER prescribe oral prednisone alone (Beck ONTT NEJM 1992 PMID 1734247; Petzold Lancet Neurol 2022 PMID 36179757)
3. IV methylprednisolone (typical ON — speeds recovery only) 1000 mg IV once daily × 3-5 d — Typical demyelinating ON where faster recovery matters functionally (Beck ONTT NEJM 1992 PMID 1734247) (Speeds recovery; does NOT change final acuity; optional (recovery occurs without it))
4. Post-IVMP oral prednisolone TAPER (taper only) 1 mg/kg then taper ~11-14 d PO once daily taper — ONLY after an IVMP pulse, per local protocol (Beck ONTT NEJM 1992 PMID 1734247) (Oral steroid permissible only as the post-IV taper; standalone oral prednisone is contraindicated (↑recurrence))
5. Oral prednisone ALONE — DO NOT PRESCRIBE contraindicated PO never as standalone — Guardrail: standalone oral prednisone doubled recurrence vs placebo in ONTT (Beck NEJM 1992 PMID 1734247) (Hard ONTT contraindication — the single most important prescribing error to avoid in optic neuritis)

Non-pharmacologic actions:
- Urgent gadolinium MRI brain + orbits for diagnosis + ONTT 15-year MS-risk stratification (Beck Arch Neurol 2008 PMID 18541792)
- Send serum AQP4-IgG + MOG-IgG (cell-based assay) if ANY atypical feature (Wingerchuk Neurology 2015 PMID 26092914; Banwell Lancet Neurol 2023 PMID 36706773)
- Rapid neuro-ophthalmology / neurology referral; counsel that typical ON usually recovers useful acuity over months even without steroid (Beck Arch Ophthalmol 1993 PMID 8512477)
- Reciprocal handoff with ophtho.acute-vision-loss.core.v1 if a competing acute cause (AION/CRAO/RD) is uncovered

AVOID / contraindication checks:
- Oral prednisone alone CONTRAINDICATED in typical optic neuritis (Beck ONTT NEJM 1992 PMID 1734247 — standalone oral prednisone doubled recurrence vs placebo; permissible ONLY as the post IVMP taper)
- Do not start MS DMTs in AQP4 NMOSD (Wingerchuk Neurology 2015 PMID 26092914 — interferon beta/natalizumab/fingolimod can worsen NMOSD; confirm AQP4 serology before chronic therapy)
- Do not delay empiric steroid for ESR or temporal artery biopsy if GCA suspected (≥50 + GCA cluster — arteritic AION mimics ON; route to rheum.giant cell arteritis.core.v1)
- No recovery at expected window is an atypical flag reopen AQP4 MOG infectious compressive workup (Petzold Lancet Neurol 2022 PMID 36179757)
- Mogad steroid is steroid dependent do not stop abruptly (Jarius J Neuroinflammation 2016 PMID 27793206 — flare ups after steroid withdrawal; slow taper)
- Steroid pulse and gadolinium MRI pregnancy and renal gating (calc.ckd_epi_2021; postpartum NMOSD relapse risk — Wingerchuk Neurology 2015 PMID 26092914)

Monitoring

Regimen monitoring:
- serial acuity colour vision fields recovery trajectory typical recovers by months without steroid (Beck Arch Ophthalmol 1993 PMID 8512477)
- non recovery at expected window re-triggers the atypical AQP4 MOG infectious compressive workup (Petzold Lancet Neurol 2022 PMID 36179757)
- NMOSD MOGAD fellow eye and next attack vigilance recovery often incomplete (Jarius J Neuroinflammation 2016 PMID 27793206)
- steroid pulse safety glucose BP mood infection
- ESR CRP trend if GCA on empiric steroid

Setting (outpatient) monitoring:
- Serial acuity/colour/fields over weeks-months; expect spontaneous recovery in typical ON (Beck Arch Ophthalmol 1993 PMID 8512477)
- No recovery at the expected window → re-open AQP4/MOG/infectious/compressive workup (atypical flag) (Petzold Lancet Neurol 2022 PMID 36179757)
- Return precautions: worsening, second eye, new neuro symptoms (NMOSD/MOGAD/MS attack)

Follow-up plan: 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.
- Close-out criterion: MS-risk-stratified DMT / NMOSD-MOGAD chronic-immunotherapy ownership handed to the routed engine_id; reciprocal acute-vision-loss handoff documented

Monitoring phase: Typical ON: serial acuity/colour/fields — most recover useful acuity by months even WITHOUT steroid (ONTT — Beck Arch Ophthalmol 1993 PMID 8512477); IVMP only changes the speed. NMOSD/MOGAD: visual recovery is often worse and incomplete — vigilance for the next attack and the fellow eye (Jarius J Neuroinflammation 2016 PMID 27793206). Failure to recover at the expected window is itself an ATYPICAL flag → re-open the AQP4/MOG/infectious/compressive workup. Steroid-pulse monitoring (glucose, BP, mood, infection). ESR/CRP trend if GCA on steroid.

Disposition

Current setting: outpatient — Confirm optic neuritis, resolve the TYPICAL-vs-ATYPICAL pivot, arrange urgent contrast MRI brain/orbits for MS-risk stratification, offer (do not mandate) IVMP to speed recovery, and NEVER prescribe oral prednisone alone (Beck ONTT NEJM 1992 PMID 1734247; Petzold Lancet Neurol 2022 PMID 36179757)

Disposition criteria:
- Typical mild ON, recovering → outpatient neuro-ophthalmology + MS-risk-stratified DMT discussion via neuro.multiple-sclerosis.core.v1 (Beck Arch Neurol 2008 PMID 18541792)
- Atypical / severe / seropositive → admit and route chronic ownership OUT by engine_id

Escalation triggers (move to higher acuity):
- Severe/NLP, bilateral simultaneous, or no recovery → admit for IVMP ± PLEX (Weinshenker Ann Neurol 1999 PMID 10589540)
- AQP4/MOG positive → chronic-immunotherapy routing to neuro.nmosd-mogad.core.v1 (Wingerchuk Neurology 2015 PMID 26092914)
- ≥50 + GCA cluster → empiric steroid + route to rheum.giant-cell-arteritis.core.v1; compressive lesion on MRI → urgent neurosurgery/ophthalmology

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Bilateral simultaneous or rapidly sequential severe optic neuropathy — NMOSD/MOGAD emergency (Wingerchuk Neurology 2015 PMID 26092914)
- [LIFE_THREATENING] Age ≥50 with optic neuropathy + new headache / jaw claudication / scalp tenderness / PMR / ↑ESR/CRP — arteritic AION mimicking optic neuritis
- [SEVERE] Severe (NLP/CF), bilateral simultaneous, painless, severe disc swelling with peripapillary haemorrhage, no recovery at the expected window, age extreme, or recurrent — ATYPICAL optic neuritis (Petzold Lancet Neurol 2022 PMID 36179757)

Citations

- 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 [PMID:1734247](https://pubmed.ncbi.nlm.nih.gov/1734247/)
- Cited evidence (PMID 8232485) [PMID:8232485](https://pubmed.ncbi.nlm.nih.gov/8232485/)
- Cited evidence (PMID 8512477) [PMID:8512477](https://pubmed.ncbi.nlm.nih.gov/8512477/)
- Cited evidence (PMID 18541792) [PMID:18541792](https://pubmed.ncbi.nlm.nih.gov/18541792/)
- Cited evidence (PMID 26092914) [PMID:26092914](https://pubmed.ncbi.nlm.nih.gov/26092914/)

Last reconciled with current guidelines: 2026-05-17.
References
  • 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 — PMID:1734247
  • Cited evidence (PMID 8232485) — PMID:8232485
  • Cited evidence (PMID 8512477) — PMID:8512477
  • Cited evidence (PMID 18541792) — PMID:18541792
  • Cited evidence (PMID 26092914) — PMID:26092914