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The Optic Neuritis Treatment Trial (ONTT) has been influential in the clinical management of optic neuritis: the key messages being that:
the use of corticosteroids does not influence the final visual outcome;
the risk of multiple sclerosis (MS) relates to the number of brain lesions on MRI.1 ,2
While the ONTT has helped the management of patients with ‘typical demyelinating’ or MS-associated optic neuritis, in our experience, this has unwittingly affected other patients who have ‘non-MS’ or ‘atypical’ optic neuritis. The risk is that this latter group is managed in a similar way to ‘typical’ optic neuritis, with infrequent use of corticosteroids, as their use does not improve the final visual outcome in ‘typical’ optic neuritis; instead, the focus of discussions is on the risk of subsequent development of MS.
However, the management of ‘non-MS’ or ‘atypical’ optic neuritis is different. In this group, the timely use of corticosteroids may influence the final visual outcome.3 We highlight the importance of this point with three clinical cases, one of which is particularly dramatic as the patient was registered as blind for 4 years before recovery on treatment. Such a response to late corticosteroids is unusual, though perhaps such late treatment is not often attempted.
In 2011, a 50-year-old, medically retired Caucasian doctor initiated a referral to the Medical Eye Unit, with a 7-year history of subacute-onset, progressive bilateral painful visual loss. The tempo was of a gradual decline, interspersed by two episodes of painful stepwise deterioration at 6 months and 2 years. His vision gradually declined, reaching its worst in 2007 to counting fingers only, at which point he was registered as blind. He continued to have discomfort with eye movements.
On direct questioning, he described right-hand paraesthesia and clumsiness for 2 weeks in 2001, 3 weeks of right-foot paraesthesia in 2002 and …
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