Indian Journal of Clinical and Experimental Ophthalmology

Print ISSN: 2395-1443

Online ISSN: 2395-1451

CODEN : IJCEKF

Indian Journal of Clinical and Experimental Ophthalmology (IJCEO) is open access, a peer-reviewed medical journal, published quarterly, online, and in print, by the Innovative Education and Scientific Research Foundation (IESRF) since 2015. To fulfill our aim of rapid dissemination of knowledge, we publish articles ‘Ahead of Print’ on acceptance. In addition, the journal allows free access (Open Access) of its content, which is likely to attract more readers and citations of articles more...


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Chaurasia and Chaurasia: To study visual and neurological outcome after treatment according to ONTT protocol


Introduction

The optic nerve begins from the optic chaisma, runs forwards, laterally and slightly downwards to the optic foramen.1 It is a flattened band, which is initially covered only by piamater, but as it enters the optic canal, it gets a covering of arachnoid mater and the periosteum of the canal is a continuation of the duramater. Thus in the optic canal the optic nerve has all three sheaths and the cerebrospinal fluid lies between pia and arachnoid matter.2

Papillitis and intraocular optic neuritis – are synonymous terms; both indicate neuritis of the ophthalmoscopically visible part of the optic nerve. Papillitis is a form of optic neuritis characterised by swelling of the optic disc – an anteriorly situated from of optic neuritis.3

Retrobulbar Neuritis – is term which Walsh uses to indicate any neuritis located far enough behind the lamina cribrirosa so that at onset its effect are not visible with the ophthalmoscope. The lesion may be confined to the core of the nerves or it may involve the entire cross-section of the nerve.4

The Optic Neuritis Treatment Trial (ONTT) randomized 457 acute optic neuritis patients within 8 days of onset to treatment with oral prednisone (1 mg/kg daily for 14 days), intravenous methylprednisolone (250 mg every 6 hours for 3 days) followed by oral prednisone (1 mg/kg daily for 11 days), or oral placebo. In almost all patients, regardless of treatment group and initial severity of visual loss, some improvement began within the first 30 days. Among the 278 patients with baseline visual acuity of 20/50 or worse, all patients improved by at least 1 line of visual acuity, and all but 6 patients improved at least 3 lines by 6 months. Although baseline visual acuity was the best predictor of the 6-month visual acuity outcome, even among those patients with severe visual loss of counting fingers or worse, visual recovery to 20/40 or better occurred in 81.8% of patients.5

We included 40 patients of optic neuritis in our study to evaluate the final ophthalmological and neurological outcome after treating them according to the ONTT protocol.

Materials and Methods

This study was conducted at Gandhi Medical College & Hamidia Hospital, Bhopal from the Eye OPD & Neurology OPD. 48 eyes 40 different patients suffering from optic neuritis were selected for the present study after obtaining approval from the institute’s scientific and ethical committee

Each patient was examined in detail under the following headings. Detailed medical and ophthalmic history was taken especially about mode, duration and course of the disease. Especially drug intake, alcoholism. Smoking, pregnancy, lactation, convulsions, pyrexia, history suggestive of TB, syphilis, neurological deficit etc.

General physical examination - with emphasis on signs of anaemia, protein calorie malnutrition, vitamin deficiency, generalized lymphadenopathy, sinusitis, septic foci. Specific emphasis on neurological examination was made.

Females – Pregnancy, lactation, menopause were noted.

Ophthalmic Examination: Local – Lid, adnexa, anterior segment of eyeball were examined. Visual acuity – Using Snellens whole line opto types, the visual acuity was recorded. Best corrected visual acuity on three consecutive follow up visits, 1st (1 month) 2nd (1 month – 6 month) 3rd (6 months – 1 year), As soon as the patient was diagnosed to be suffering from optic neuritis, he was put on the following treatment.

  1. According to optic neuritis treatment trial (ONTT) I.V. methyl prednisolone 1000 mg per day for three days than oral prednisolone (1 mg / kg daily) for 11 days.

  2. Only oral steroids for patients who were not affording.

  3. Multivitamins (especially BI, B6, B12)

  4. Antacids

Results

Table 1

Treatment modalities in different cases

Total

ONTT (Optic neuritis treatment trial)

OS (Oral Steroids)

40

35

5

100%

87.5%

12.5%

Maximum patient 35(87.5) treated according to ONTT protocol while 5 (12.5%) treated with oral steroids.

Table 2

BCVA after 1st follow-up

Visual acuity less than or equal to

No of eyes

Percentage

6/60

14

29.8

6/36

9

19.1

6/24

1

2.1

6/18

0

0

6/12

9

19.1

6/9

4

8.5

6/6

10

21.3

Total

47

100%

Maximum 33 eyes (70.2%) attain BCVA > 6/36 after 1st follow-up (with in 1 month) table also shows 10(21.3%) eyes attain BCVA of 6/6 after 1st follow-up.

Table 3

BCVA after 2nd follow up

Visual acuity less than or equal to

No of eyes

Percentage

6/60

11

25.6

6/36

6

13.9

6/24

1

2.3

6/18

0

0

6/12

8

18.6

6/9

6

13.9

6/6

11

25.6

Total

43

100%

11 eyes (25 6% attain BCVA 6/6 after II follow-up

Discussion

As mentioned in the previous studies, time was a very important factor in the matter of rapid response of treatment. When started early, even seemingly worst cases recovered well.6 This is true in this series also, patients presented early recovered with 6/6-6/9 vision in Ist follow-up in comparison to patient presented after 1 week (13.2%), 2 weeks (0%), 3 weeks (0%).

In our study 39.5 patients presented with blurred hyperemic disc and at the time of IIIrd follow-up 25 (61%) out of 41 eyes showed normal color of the disc and 15 (36.6%) eyes showed a generalized pallor of the disc though vision in these eyes was 6/12 or better sowing thereby that pallor of the disc and vision do not always correspond, remarked that degree of pallor and defect of vision did not always correspond.7 There might be a vision of 6/6 together with definite pallor of the disc.

Most of the cases responded to i.v. steroids and 5 cases which had oral steroid treatment (due to non affordability) had a delayed recovery of visual acuity. Cleary et al6 stated that inflammation plays an important part in the product of clinical deficit and that its resolution is an important step in clinical remission. Thus steroids help in optic neuritis by controlling inflammation. A study found that although a trend towards faster recovery in favour of prednosolone was noted, no long term benefit was observed after 1 year.8, 9

Conclusion

General prognosis for recovery of vision was good and was slightly worse in more severely affected cases in the present series. Pallor of the optic disc and defect of vision did not always correspond–3 eyes which showed temporal pallor of the disc at the end of follow up had a final vision of 6/9 or better in each eye.

Source of Funding

None.

Conflict of Interest

The authors declare no conflict of interest.

References

1 

AC Arnold Evolving management of optic neuritis and multiple sclerosisAm J Ophthalmol2005139611018

2 

S Ismail WHW Hazabbah NI Muhd-Nor J Daud Z Embong Clinical Profile and Aetiology of Optic Neuritis in Hospital Universiti Sains Malaysia - 5 Years Review Ismail Shatriah, Wan Hazabbah Wan Hitam, Muhd-Nor Nor-Idahriani, Daud Jakiyah, Embong ZunainaMed J Malaysia201267215964

3 

R Pokroy G Modi D Saffer Optic neuritis in urban black African communityEye (Lond)200115Pt 446973

4 

JL Keltner CA Johnson RW Beck PA Cleary JO Spurr Quality control functions of the Visual Field Reading Center (VFRC) for the Optic Neuritis Treatment Trial (ONTT)Control Clin Trials199314214359

5 

NJ Volpe The Optic Neuritis Treatment Trial: A Definitive Answer and Profound Impact With Unexpected ResultsArch Ophthalmol20081267996910.1001/archopht.126.7.996

6 

PA Cleary RW Beck LB Bourque JC Backlund PH Miskala Visual symptoms after optic neuritis. Results from the Optic Neuritis Treatment TrialJ Neuroophthalmol19971711823

7 

GA Chrousos JC Kattah RW Beck PA Cleary Side effects of glucocorticoid treatment. Experience of the Optic Neuritis Treatment TrialJAMA19932691621102

8 

RW Beck JD Trobe What we have learned from the Optic Neuritis Treatment TrialOphthalmology19951021015048

9 

RW Beck Corticosteroid treatment of optic neuritis: a need to change treatment practices. The Optic Neuritis Study GroupNeurology199242611335



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Article type

Original Article


Article page

728-730


Authors Details

Yogita Chaurasia, I D Chaurasia*


Article History

Received : 07-06-2021

Accepted : 26-06-2021

Available online : 03-01-2022


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