Appropriateness of immunomodulation for clinically isolated optic neuritis pondered

Immune modulatory therapy can be useful in preventing further attacks, preserving vision, and preventing disability in patients with clinically isolated optic neuritis, especially in those who are at high risk of developing multiple sclerosis (MS), said Kathleen B. Digre, MD, director of neuro-ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City, United States.

But such treatment is expensive and can have serious side effects, so it should not be prescribed for patients with optic neuritis who are at low risk of developing MS, according to Karl C. Golnik, MD, MEd, clinical professor of ophthalmology, University of Cincinnati, and neuro-ophthalmologist, Cincinnati Eye Institute, Cincinnati, OH, United States.

The two took sides in a debate over the use of immunomodulation therapy in cases of clinically isolated optic neuritis during a symposium about current and emerging controversies in neuro-ophthalmology.

Dr. Digre described the case of a 28-year-old female patient presenting with multiple plaques.

If optic neuritis attacks aren't prevented, she said, "that will increase the disease burden and, eventually, without treatment, could lead to secondary progressive MS."

Vision should be preserved, Dr. Digre added, "because the more attacks one gets, the more zonal loss that one has, the more irreversible the axonal injury is, and we cannot bring those axons back."

The prevention of disability should be a goal "because MS a very disabling condition for those people who have it," she said.

Representing the other side of the debate, Dr. Golnik cited the side effects and cost associated with immunomodulation.

In the United States, the annual cost of the therapy for one patient is $14,000, he said. Use of immunomodulation can result in skin necrosis, abnormal liver function, flu-like symptoms, abnormal blood counts, and neutralizing antibodies, Dr. Golnik added.

Patients with typical optic neuritis can present as low or high risk, he said, Seventy-eight percent of low-risk patients do not develop MS, he said, adding that intravenous methylprednisolone therapy can be prescribed to increase the rate of recovery in these patients.

"Or you could do nothing and repeat an MRI in 6 months and look for plaques," he said.

Even in high-risk patients with one or more plaques, 44% do not develop MS within 10 years, Dr. Golnik noted. "So if you treat everybody, you're treating 44%-almost half of the patients-with these medications, who presumably don't need them."

Peter A. Quiros, MD, assistant professor of ophthalmology, Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, United States, concluded the session by noting that the role of the clinician is the present the facts to the patient in an unbiased manner and allow the patient to make his or her own choices regarding treatment.

No long-term studies have examined the effectiveness of immunomodulation in patients with clinically isolated optic neuritis in whom the risk of developing MS is low, he said. Although clinicians may consider approaching treatment of such patients more conservatively than they do treatment for patients at high risk, he said, the prevention of disability is a worthy goal.

"Time is brain," Dr. Quiros said.