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Visual Outcome after Oral versus Intravenous Methylpredisolone Therapy for Bilateral Optic Neuritis in Adults

Email : heme@unbrah.ac.id Abstract Introduction: Bilateral optic neuritis in adults is rarer then unilateral optic neuritis. The purpose of this study was to know the clinical profile and to know the visual outcome of bilateral optic neuritis in adult patients after oral versus intravenous methylprednisolone therapy. Methods: A retrospective review of patients with bilateral optic neuritis referred to dr.Sardjito General Hospital, Yogyakarta from 2011-2014. The data consisted of bilateral optic neuritis, unassociated with other pathologic processes. There are two groups of patients: Group A taking oral methylprednisolone 1mg/kgBB and Group B received intravenous methylprednisolone (as ONTT guideline). Visual acuity, visual field with Goldmann Perimetry, RAPD (Relative Afferent Puppilary Defect), Ishihara test and direct ophthalmoscopy evaluation were recorded and analysed in both group at baseline, 1 week, 1 month and 3 months follow up. Results: Nineteen women and 9 men, with age range of 18-54 years old, had bilateral optic neuritis. The majority of the patients suffered from retrobulbar neuritis (43%), papilitis (39%) and neuroretinitis (18%). The average visual acuity before treatment in Group A was 0.22 ± 0.29 and in Group B had poorer average visual acuity 0.03±0.04 (p>0.05). But the trend of visual recovery in Group B with visual acuity at baseline worsen, the recovery of visual acuity was faster and better at one week. After one month the visual acuity was comparable in both groups (p>0.05). Conclusions: Visual improvement in early period of adult bilateral optic neuritis was similar after oral and intravenous methylprednisolone therapy.


I. INTRODUCTION
Optic neuritis is the inflammation of the optic nerve. Clinically, the patients present with sudden or subacute diminution of vision loss with ocular pain (especially on ocular movements), loss of color vision, decreased of brightness, and visual field defects as central, paracentral, arcuate, or altitudinal defects. 1,2,3 The attack is usually unilateral in 70% of adults and bilateral in 30%. 4 Bilateral optic neuritis is usually thought to affect children, often follows a viral syndrome, and is not typically associated with subsequent multiple sclerosis. 2 In contrast, in adults simultaneous bilateral acute optic neuritis has been considered rare particularly in individuals without known systemic inflammatory or autoimmune disorders. 4 Adult onset optic neuritis is typically unilateral and is commonly linked to multiple sclerosis. 5 The majority of patients (95%) recover spontaneously with a visual acuity of 20/40 or better within a year after an attack; but some have a lasting visual deficit. 3 Contrast sensitivity of the affected eye is found last to recover. Vision recovery is significant regardless of the treatment. 3 Few reports describe the clinical course, recovery, and outcome after treatment with steroid therapy. 4 This study was aimed to compare steroid therapy given by oral versus intravenous route, about the time course of visual recovery, during a one week until 3 months follow up for bilateral optic neuritis in adult patients.

II. METHODS
We performed a retrospective review of patient records and who presented with acute bilateral optic neuritis in the Ophthalmology Department dr.Sardjito General Hospital, Yogyakarta during 3,5 year period from January 2011 to June 2014. Patients were included if they presented with new onset of acute bilateral visual loss diagnosed as bilateral optic neuritis and the age >18 years.
Exclusion criteria included known multiple sclerosis, previous optic neuritis or myelopathy, known systemic disorders associated with optic neuropathy, use of medications related to toxic optic neuropathy, known uveitis, or known systemic or intracranial neoplasm.
Visual function testing was performed for each eye at baseline and at the follow up of one week, 1 month, and 3 months. Visual acuity was assessed with wall projected Snellen letter charts and the results expressed in decimal notation. Perimetry was performed on Goldmann bowl projecting manual kinetic perimeter. Colour vision deficits were recorded using Ishihara colour plates. The presence or absence of pain with extraocular movement was documented.
The patients are divided into 2 groups. Group A received oral methylprednisolone 1mg/kgBB for about 1 weeks followed by gradual tapering depending on the clinical course, whereas Group B received intravenous methylprednisolone (1gr per day followed by 11 days of low-dose oral methylprednislone as ONTT guide followed by a gradual tapering depending on the clinical course. Outcome measure and statistical analysis The visual acuity are measured at the baseline, one week, one month and three months follow up after receiving therapy: oral methylprednisolone (Group A) or intravenous methylprednisolone (Group B). We analysed the visual acuity for the worsen eye at the baseline, determined by the visual acuity and standard deviation. We compared the baseline to one week, one month and three months follow up after receiving therapy using Kruskal-Wallis test. The examination results for one eye only, the worsen eye, because the baseline visual acuity loss strongly correlated with the visual acuity in the fellow eye.

III. RESULT
Twenty-eight patients suffering from bilateral optic neuritis were included in this study. Mean duration of the onset symptoms at arrival was 14 days. Mean patients age was 35.3±10.7 years (age range 18-54 years). Nineteen patients (68%) were females, nine patients (42%) were males. Twelve patients (43%) (Group A) received oral methylprednisolone (1mg/kgBB) for one week then tapered off. Sixteen patients (57%) (Group B) received intravenous methylprednisolone based on ONTT guideline.

IV. DISCUSSION
This study showed a female preponderance (68%), different with other study of optic neuritis that found male preponderance. 4 Patients were within age range 19-54 years. It was within the same age range with other study that found in aged range 18-64 years. 4 The majority patients (43%) had neuritis retrobulbar, 39% had papillitis and 18% had neuroretinitis. This was different with other study of optic neuritis. Shresta, et.al. was found that the most common type of optic neuritis in unilateral optic neuritis was papilitis (74,2%), retrobulbar (22,6%) and neuroretinitis (3,2%). 5 Although the presentation and severity of visual loss in our cases of bilateral optic neuritis was dramatic, recovery was good to excellent in both group patients. The bilateral vision loss typically improves with corticosteroid therapy without additional immunomodulatory therapy and good visual recovery is anticipated even after gradual withdrawal of therapy. 4 Visual field defect that found in our study were:

V. CONCLUSIONS
Acute bilateral optic neuritis in adults occurs quite often than previously thought. The bilateral vision loss typically improves with corticosteroid therapy both in oral methylprednisolone group or intravenous methylprednisolone group with the same result in one week and one month. But, intravenous methylprednisolone can be considered in patients with worsen visual acuity at baseline, because the recovery of visual acuity showed faster and better at the early period..