Optic Neuritis¶
DIAGNOSIS: Optic Neuritis ICD-10: H46.9 (Optic neuritis, unspecified); H46.00 (Optic papillitis, unspecified eye); H46.10 (Retrobulbar neuritis, unspecified eye); G36.0 (Neuromyelitis optica - if NMOSD confirmed); H46.8 (Other optic neuritis)
CPT CODES: 85025 (CBC with differential), 80053 (CMP), 85652 (ESR), 86140 (CRP), 82947 (Blood glucose), 81001 (Urinalysis), 86235 (Mayo CDS1 Panel - AQP4-IgG + MOG-IgG by FACS), 86038 (ANA), 84443 (TSH), 82607 (Vitamin B12), 82746 (Folate), 86592 (RPR/VDRL), 86701 (HIV), 82164 (ACE level), 86618 (Lyme serology), 83036 (HbA1c), 86225 (Anti-dsDNA), 86039 (ANCA panel), 86335 (Serum protein electrophoresis), 81401 (Mitochondrial DNA testing), 82525 (Copper, ceruloplasmin), 82390 (Copper, ceruloplasmin), 86255 (Paraneoplastic panel - anti-CRMP5/CV2), 70543 (MRI orbits with contrast - fat-suppressed T1, STIR), 70553 (MRI brain with and without contrast - MS protocol), 72156 (MRI C-spine with and without contrast), 95930 (Visual evoked potentials - VEP), 92134 (OCT - Optical coherence tomography), 92083 (Formal visual field testing - Humphrey 30-2 or 24-2), 71260 (CT chest), 78816 (PET-CT), 70480 (CT orbits), 92235 (Fluorescein angiography), 62270 (Opening pressure), 89051 (Cell count - tubes 1 and 4), 84157 (Protein), 87205 (Gram stain and culture), 87070 (Gram stain and culture), 83916 (Oligoclonal bands - CSF AND serum), 86327 (IgG index), 89050 (Cytology), 86593 (VDRL - CSF) SYNONYMS: Optic neuropathy (inflammatory), retrobulbar neuritis, papillitis, demyelinating optic neuropathy, acute optic neuritis, ON, MS-associated optic neuritis, clinically isolated syndrome (CIS) - optic neuritis, optic perineuritis, MOGAD optic neuritis, NMOSD optic neuritis SCOPE: Acute evaluation and management of optic neuritis in adults. Covers typical demyelinating optic neuritis, atypical features requiring expanded workup, MS risk stratification, ONTT-based treatment, and NMO/MOG antibody evaluation. For established MS with optic neuritis as a relapse, can also use "MS - Exacerbation" template.
VERSION: 1.1 CREATED: January 27, 2026 REVISED: January 30, 2026
STATUS: Approved
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
CLINICAL PEARL: The Optic Neuritis Treatment Trial (ONTT) established that IV methylprednisolone accelerates visual recovery but does not change final visual outcome. Oral prednisone alone at standard doses (1 mg/kg/day) was associated with increased recurrence rate and should NOT be used as monotherapy. Most patients (90%+) recover vision to 20/40 or better within 1 year.
SECTION A: ACTION ITEMS¶
1. LABORATORY WORKUP¶
1A. Essential/Core Labs¶
| Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| CBC with differential (85025) | STAT | STAT | ROUTINE | - | Infection screen, baseline before steroids | Normal |
| CMP (80053) | STAT | STAT | ROUTINE | - | Metabolic screen, renal function for contrast | Normal |
| ESR (85652) | STAT | STAT | ROUTINE | - | Inflammatory/vasculitis screen; elevated in GCA | Normal (<20 mm/hr); elevated in GCA |
| CRP (86140) | STAT | STAT | ROUTINE | - | Inflammatory marker | Normal |
| Blood glucose (82947) | STAT | STAT | ROUTINE | - | Pre-steroid baseline | Normal |
| Urinalysis (81001) | STAT | STAT | ROUTINE | - | UTI screen before steroids | Negative |
1B. Extended Workup (Second-line)¶
| Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| Mayo CDS1 Panel - AQP4-IgG + MOG-IgG by FACS (86235) | URGENT | URGENT | ROUTINE | - | Combined NMO/MOGAD screen; critical for atypical cases | Both negative |
| ANA (86038) | URGENT | ROUTINE | ROUTINE | - | Lupus/connective tissue disease | Negative or low titer |
| TSH (84443) | - | ROUTINE | ROUTINE | - | Thyroid eye disease (Graves ophthalmopathy) | Normal |
| Vitamin B12 (82607) | - | ROUTINE | ROUTINE | - | Nutritional optic neuropathy | Normal (>300 pg/mL) |
| Folate (82746) | - | ROUTINE | ROUTINE | - | Nutritional optic neuropathy | Normal |
| RPR/VDRL (86592) | - | ROUTINE | ROUTINE | - | Neurosyphilis | Negative |
| HIV (86701) | - | ROUTINE | ROUTINE | - | HIV-associated optic neuropathy | Negative |
| ACE level (82164) | - | ROUTINE | ROUTINE | - | Neurosarcoidosis | Normal |
| Lyme serology (86618) | - | ROUTINE | ROUTINE | - | Endemic areas; Lyme optic neuropathy | Negative |
| HbA1c (83036) | - | ROUTINE | ROUTINE | - | Glycemic status before steroids | <5.7% |
Note: Mayo CDS1 Panel preferred for combined AQP4 + MOG testing. Cell-based assay (FACS) is gold standard. If unavailable, order AQP4-IgG (Mayo NMOFS) and MOG-IgG (Mayo MOGFS) separately.
1C. Rare/Specialized (Refractory or Atypical)¶
| Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| Anti-dsDNA (86225) | - | EXT | EXT | - | If ANA positive; SLE screen | Negative |
| Anti-SSA/SSB - Ro/La (86235) | - | EXT | EXT | - | Sjogren syndrome | Negative |
| ANCA panel (86039) | - | EXT | EXT | - | CNS/orbital vasculitis | Negative |
| Serum protein electrophoresis (86335) | - | EXT | EXT | - | Paraproteinemic optic neuropathy | No M-spike |
| Mitochondrial DNA testing (81401) | - | - | EXT | - | Leber hereditary optic neuropathy (LHON) | Normal |
| Copper, ceruloplasmin (82525, 82390) | - | - | EXT | - | Wilson disease | Normal |
| Paraneoplastic panel - anti-CRMP5/CV2 (86255) | - | EXT | EXT | - | Paraneoplastic optic neuropathy | Negative |
2. DIAGNOSTIC IMAGING & STUDIES¶
2A. Essential/First-line¶
| Study (CPT) | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| MRI orbits with contrast - fat-suppressed T1, STIR (70543) | URGENT | URGENT | ROUTINE | - | Within 24-48h | Optic nerve enhancement, swelling; enhancement >50% nerve length suggests atypical/NMOSD | GFR <30, gadolinium allergy |
| MRI brain with and without contrast - MS protocol (70553) | URGENT | URGENT | ROUTINE | - | With orbit MRI | Demyelinating lesions (periventricular, juxtacortical, infratentorial); determines MS risk | GFR <30, gadolinium allergy |
| MRI C-spine with and without contrast (72156) | - | ROUTINE | ROUTINE | - | Within 1 week if MS suspected | Cord lesions supporting MS diagnosis | GFR <30, gadolinium allergy |
MS protocol should include: 3D FLAIR, 3D T1 pre/post-contrast, T2, DWI. For orbits: fat-suppressed T1 post-contrast, STIR/T2 coronal.
2B. Extended¶
| Study (CPT) | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| Visual evoked potentials - VEP (95930) | - | ROUTINE | ROUTINE | - | During workup | Prolonged P100 latency (confirms optic nerve dysfunction) | None significant |
| OCT - Optical coherence tomography (92134) | - | - | ROUTINE | - | Baseline and at 3-6 months | RNFL thickening acutely; thinning at follow-up indicates axonal loss | None significant |
| Formal visual field testing - Humphrey 30-2 or 24-2 (92083) | - | ROUTINE | ROUTINE | - | At presentation and follow-up | Central/cecocentral scotoma typical; document baseline | Patient cooperation required |
Note: OCT typically available only in outpatient neuro-ophthalmology. RNFL thickening >15% of fellow eye acutely suggests papillitis.
2C. Rare/Specialized¶
| Study (CPT) | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| CT chest (71260) | - | EXT | EXT | - | If sarcoidosis suspected | Hilar lymphadenopathy | Contrast allergy |
| PET-CT (78816) | - | EXT | EXT | - | If malignancy/paraneoplastic suspected | FDG-avid lesions | Pregnancy, uncontrolled diabetes |
| CT orbits (70480) | STAT | - | - | - | Only if MRI unavailable/contraindicated | Optic nerve enlargement, orbital mass | Contrast allergy |
| Fluorescein angiography (92235) | - | - | EXT | - | If retinal/vascular pathology suspected | Disc leakage, vascular abnormality | Dye allergy |
LUMBAR PUNCTURE¶
Indication: Not routinely required for typical optic neuritis. Consider if: (1) atypical features present, (2) need to support MS diagnosis (OCBs for dissemination in time), (3) concern for infectious or inflammatory etiology, (4) poor response to steroids.
Timing: ROUTINE if indicated; URGENT if infection suspected
Volume Required: 15-20 mL (standard diagnostic)
| Study (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| Opening pressure (62270) | URGENT | ROUTINE | ROUTINE | - | Rule out elevated ICP (papilledema mimics) | 10-20 cm H2O |
| Cell count - tubes 1 and 4 (89051) | URGENT | ROUTINE | ROUTINE | - | Inflammation, rule out infection | WBC <50 (mild pleocytosis acceptable); RBC 0 |
| Protein (84157) | URGENT | ROUTINE | ROUTINE | - | Elevated in inflammation | Normal to mildly elevated (<100 mg/dL) |
| Glucose with serum glucose (82947) | URGENT | ROUTINE | ROUTINE | - | Low in infection | Normal (>60% serum) |
| Gram stain and culture (87205, 87070) | URGENT | ROUTINE | ROUTINE | - | Rule out infection | No organisms |
| Oligoclonal bands - CSF AND serum (83916) | - | ROUTINE | ROUTINE | - | Intrathecal IgG synthesis (supports MS) | >=2 CSF-specific bands (not in serum) |
| IgG index (86327) | - | ROUTINE | ROUTINE | - | Intrathecal antibody synthesis | >0.7 = elevated |
| Cytology (89050) | - | ROUTINE | ROUTINE | - | Rule out malignancy | Negative |
| VDRL - CSF (86593) | - | ROUTINE | ROUTINE | - | Neurosyphilis | Negative |
Special Handling: OCBs stable at 4°C for days; send paired serum.
Contraindications: Elevated ICP without imaging, coagulopathy (INR >1.5, platelets <50K), skin infection at LP site
3. TREATMENT¶
3A. Acute/Emergent¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Methylprednisolone | IV | Acute optic neuritis - accelerates visual recovery per ONTT | 1000 mg :: IV :: daily x 3 days :: 1000 mg IV daily for 3 days; infuse over 1-2 hours; followed by oral prednisone taper | Active untreated infection; uncontrolled diabetes; active psychosis; severe hypertension | Glucose q6h (target <180); BP; mood; sleep; I/O | STAT | STAT | - | - |
| Prednisone oral taper | PO | Following IV methylprednisolone per ONTT protocol | 1 mg/kg :: PO :: daily x 11 days :: 1 mg/kg/day (max 80 mg) x 11 days following 3 days IV steroids; then discontinue or rapid taper | Same as IV steroids | Glucose; BP; mood; GI prophylaxis | - | ROUTINE | ROUTINE | - |
| Omeprazole | PO | GI prophylaxis during steroids | 20 mg :: PO :: daily :: 20-40 mg daily during steroid course | PPI allergy; osteoporosis (long-term) | None routine | STAT | STAT | ROUTINE | - |
| Insulin sliding scale | SC | Steroid-induced hyperglycemia | Per protocol :: SC :: PRN :: Per institutional protocol if glucose >180 mg/dL | Hypoglycemia risk | Glucose q6h | STAT | STAT | - | - |
IMPORTANT: Oral prednisone alone (without preceding IV steroids) should NOT be used. ONTT showed increased recurrence rate with standard-dose oral prednisone monotherapy.
3B. Symptomatic Treatments¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Acetaminophen | PO | Pain with eye movement | 650-1000 mg :: PO :: q6h PRN :: 650-1000 mg PO q6h as needed for pain; max 3000 mg/day (2000 mg if liver disease) | Hepatic impairment; chronic alcohol use | LFTs if prolonged use | ROUTINE | ROUTINE | ROUTINE | - |
| Ibuprofen | PO | Pain with eye movement | 400-800 mg :: PO :: q8h PRN :: 400-800 mg PO q8h as needed for pain; max 2400 mg/day; take with food | Renal impairment; GI bleeding; concurrent anticoagulation | Renal function if prolonged | ROUTINE | ROUTINE | ROUTINE | - |
| Gabapentin | PO | Persistent periorbital pain/neuropathic symptoms | 300 mg :: PO :: qHS :: Start 300 mg qHS; increase by 300 mg every 1-3 days; target 900-1800 mg/day divided TID | Renal impairment (adjust dose) | Sedation; dizziness | - | ROUTINE | ROUTINE | - |
| Artificial tears | TOP | Dry eye secondary to reduced blink or lagophthalmos | 1-2 drops :: TOP :: q2-4h PRN :: Preservative-free artificial tears 1-2 drops q2-4h as needed | None | None | ROUTINE | ROUTINE | ROUTINE | - |
3C. Second-line/Refractory¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Plasmapheresis (PLEX) | PLEX | Steroid-refractory or severe vision loss | 5-7 exchanges :: PLEX :: qod :: 5-7 exchanges every other day; typical volume 1-1.5 plasma volumes | Hemodynamic instability; sepsis; line contraindication | BP; electrolytes; coags; fibrinogen; line infection | - | URGENT | - | - |
| IVIG | IV | Steroid-refractory (alternative to PLEX) | 0.4 g/kg :: IV :: daily x 5 days :: 0.4 g/kg/day for 5 days (total 2 g/kg); infuse slowly day 1 | IgA deficiency; renal failure; thrombosis risk | Renal function; headache; thrombosis | - | URGENT | - | - |
| Extended IV steroids | IV | Incomplete response to 3-day course | 1000 mg :: IV :: daily :: Extend to 5-7 total days if inadequate response | Same as initial course | Same as initial course | - | ROUTINE | - | - |
3D. Disease-Modifying Therapies (If MS/NMOSD/MOGAD Confirmed)¶
DMT initiation requires confirmed diagnosis and specialist involvement. Not initiated in ED or ICU. See specific disease templates for detailed DMT options.
| Treatment | Route | Indication | Dosing | Pre-Treatment Requirements | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|---|
| MS DMT (various) | Variable | If MS diagnosed based on MRI + clinical criteria | See MS - New Diagnosis template :: - :: - :: See MS - New Diagnosis template | Per specific DMT | Per specific DMT | Per specific DMT | - | - | ROUTINE | - |
| Rituximab | IV | NMOSD (AQP4-IgG positive) | 1000 mg :: IV :: q2wk x 2 then q6mo :: 1000 mg IV days 1 and 15; maintenance 1000 mg q6 months | Hepatitis B serology; TB test; immunoglobulins | Active Hep B; active infection | CD19/20; immunoglobulins annually | - | - | ROUTINE | - |
| Eculizumab (Soliris) | IV | NMOSD (AQP4-IgG positive) - FDA approved | 900 mg :: IV :: weekly x 4 then q2wk :: 900 mg weekly x 4; then 1200 mg at week 5; then 1200 mg q2 weeks | Meningococcal vaccination (2 weeks prior) | Unresolved Neisseria infection | CBC; LFTs; signs of meningococcal infection | - | - | ROUTINE | - |
| Immunosuppression (MOGAD) | Variable | MOGAD (MOG-IgG positive) with relapsing course | Per agent :: Variable :: - :: Rituximab, azathioprine, or mycophenolate per specialist | Per specific agent | Per specific agent | Per specific agent | - | - | ROUTINE | - |
4. OTHER RECOMMENDATIONS¶
4A. Referrals & Consults¶
| Recommendation | ED | HOSP | OPD | ICU |
|---|---|---|---|---|
| Neuro-ophthalmology referral for comprehensive evaluation and follow-up | URGENT | URGENT | ROUTINE | - |
| Neurology/MS specialist referral if brain MRI shows demyelinating lesions | URGENT | URGENT | ROUTINE | - |
| Ophthalmology referral if neuro-ophthalmology unavailable or alternate diagnosis suspected | URGENT | URGENT | ROUTINE | - |
| MS specialist/Neuroimmunology for DMT discussion if MS criteria met | - | ROUTINE | ROUTINE | - |
| Low vision rehabilitation if significant persistent visual impairment | - | - | ROUTINE | - |
| Occupational therapy for ADL adaptation if functional visual impairment | - | ROUTINE | ROUTINE | - |
| Social work for disability resources if visual impairment affects employment | - | - | ROUTINE | - |
4B. Patient Instructions¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Vision typically improves over 2-4 weeks; 90%+ recover to 20/40 or better within 1 year | ROUTINE | ROUTINE | ROUTINE |
| Return immediately if vision worsening after initial improvement (may indicate new attack or alternate diagnosis) | STAT | STAT | ROUTINE |
| Return if new symptoms: weakness, numbness, imbalance, bladder problems (may indicate MS) | STAT | STAT | ROUTINE |
| Do not drive if vision in affected eye prevents safe driving; check with state DMV regarding vision requirements | ROUTINE | ROUTINE | ROUTINE |
| Heat may temporarily worsen symptoms (Uhthoff phenomenon) - this is not a new attack or permanent worsening | ROUTINE | ROUTINE | ROUTINE |
| Expect temporary steroid side effects: insomnia, mood changes, increased appetite, metallic taste during IV infusion | ROUTINE | ROUTINE | - |
| Do not stop oral prednisone abruptly if on taper (adrenal suppression risk) | - | ROUTINE | ROUTINE |
| Monitor blood sugars if diabetic - steroids elevate glucose | ROUTINE | ROUTINE | ROUTINE |
| Avoid sick contacts while on high-dose steroids (immunosuppression) | ROUTINE | ROUTINE | - |
| Keep follow-up appointments - important to monitor for MS development | - | ROUTINE | ROUTINE |
| Contact physician if fever, new headache, or worsening vision on steroids | STAT | STAT | ROUTINE |
4C. Lifestyle & Prevention¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Smoking cessation - smoking increases MS conversion risk and worsens outcomes | ROUTINE | ROUTINE | ROUTINE |
| Vitamin D supplementation 2000-5000 IU daily (target serum 25-OH vitamin D >40 ng/mL) - low levels associated with MS risk | - | ROUTINE | ROUTINE |
| Avoid prolonged heat exposure (hot tubs, saunas, exercising in heat) which can temporarily worsen vision (Uhthoff) | - | ROUTINE | ROUTINE |
| Use sunglasses if photophobia present | ROUTINE | ROUTINE | ROUTINE |
| Regular aerobic exercise as tolerated once acute symptoms resolve | - | - | ROUTINE |
| Adequate sleep (7-8 hours nightly) and stress management | - | ROUTINE | ROUTINE |
| Eye protection during activities if monocular vision (loss of depth perception) | ROUTINE | ROUTINE | ROUTINE |
SECTION B: REFERENCE¶
5. DIFFERENTIAL DIAGNOSIS¶
| Alternative Diagnosis | Key Distinguishing Features | Tests to Differentiate |
|---|---|---|
| NMOSD-associated optic neuritis | Severe vision loss (often <20/200); bilateral simultaneous or sequential; poor recovery; longitudinally extensive optic nerve enhancement (>50% nerve length) | AQP4-IgG positive (Mayo CDS1 or NMOFS); MRI pattern |
| MOGAD-associated optic neuritis | Often bilateral; anterior optic nerve involvement; perineural enhancement ("optic nerve sheath sign"); disc edema more prominent; better steroid response; tends to relapse | MOG-IgG positive (Mayo CDS1 or MOGFS) |
| Anterior ischemic optic neuropathy (AION) | Sudden painless vision loss; altitudinal field defect; disc edema with hemorrhages; age >50; vascular risk factors (hypertension, diabetes) | ESR/CRP for GCA; fluorescein angiography; cardiovascular risk assessment |
| Giant cell arteritis (GCA) | Age >50; headache; jaw claudication; scalp tenderness; elevated ESR/CRP; bilateral risk | ESR, CRP, temporal artery biopsy; prompt treatment to prevent fellow eye |
| Papilledema | Bilateral disc edema; transient visual obscurations; headache worse lying down; no RAPD unless asymmetric | LP with elevated opening pressure; MRI/MRV for venous sinus thrombosis |
| Compressive optic neuropathy | Progressive vision loss; proptosis; may have disc pallor or edema; optic canal mass | MRI orbits showing mass lesion; CT for bony detail |
| Leber hereditary optic neuropathy (LHON) | Painless; young males; sequential bilateral (weeks to months); central scotoma; no enhancement on MRI | Mitochondrial DNA testing (mutations: 11778, 3460, 14484) |
| Toxic/nutritional optic neuropathy | Bilateral symmetric; ethambutol, methanol, B12/folate deficiency; cecocentral scotoma | B12, folate, medication history, alcohol use |
| Neurosyphilis | May mimic optic neuritis; other neurologic signs; risk factors | RPR/VDRL, FTA-ABS, CSF VDRL |
| Sarcoidosis | Granulomatous optic neuropathy; uveitis; other systemic involvement | ACE, chest CT, tissue biopsy |
| Idiopathic intracranial hypertension (IIH) | Bilateral disc edema; obese young female; headache; transient visual obscurations | LP with elevated opening pressure; normal MRI/MRV |
6. MONITORING PARAMETERS¶
| Parameter | Frequency | Target/Threshold | Action if Abnormal | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| Visual acuity | Daily inpatient; each visit OPD | Improvement by 3+ Snellen lines | If no improvement by 2 weeks, reconsider diagnosis or escalate treatment | STAT | ROUTINE | ROUTINE | - |
| Color vision (Ishihara or HRR plates) | Baseline and follow-up | Normal or improving | Persistent dyschromatopsia suggests residual dysfunction | - | ROUTINE | ROUTINE | - |
| Pupillary exam (RAPD) | Daily inpatient; each visit OPD | RAPD diminishing | Persistent or worsening RAPD concerning | STAT | ROUTINE | ROUTINE | - |
| Blood glucose | Q6h during IV steroids | <180 mg/dL | Insulin sliding scale; endocrine consult if persistent >250 | STAT | ROUTINE | - | - |
| Blood pressure | Q shift during steroids | <160/100 mmHg | Antihypertensives PRN | STAT | ROUTINE | - | - |
| Mood and sleep | Daily during steroids | No psychosis, mania, severe insomnia | Psychiatry consult; consider dose reduction | - | ROUTINE | - | - |
| Visual field (formal) | Baseline, 1 month, 3 months, 6 months | Improving or stable | Worsening field concerning for progression | - | - | ROUTINE | - |
| OCT (RNFL thickness) | Baseline, 3 months, 6 months | Thinning plateaus by 6 months | >20 micron loss associated with poorer outcome | - | - | ROUTINE | - |
| MRI brain (follow-up) | 3-6 months after initial; annually if MS risk | No new lesions | If new lesions: MS diagnosed, start DMT | - | - | ROUTINE | - |
| NMO/MOG antibodies (recheck) | Repeat at 3-6 months if initially negative but atypical features | Remain negative | If seroconversion: diagnosis changes, different treatment | - | - | ROUTINE | - |
7. DISPOSITION CRITERIA¶
| Disposition | Criteria |
|---|---|
| Discharge home | Mild-moderate vision loss with stable exam; able to perform ADLs safely; IV steroids completed or not indicated; reliable follow-up within 1-2 weeks with neuro-ophthalmology or neurology; understands return precautions |
| Admit to floor | Severe vision loss (20/200 or worse); bilateral involvement; diagnostic uncertainty requiring expedited workup; unable to care for self safely at home due to vision loss; IV steroids indicated and outpatient infusion not available |
| Admit to ICU | Not typically required for isolated optic neuritis; consider if concurrent severe neurologic involvement (e.g., NMOSD with myelitis and respiratory compromise) |
| Transfer to higher level | Neuro-ophthalmology or MS specialist not available; PLEX needed but unavailable; MRI unavailable for urgent imaging |
8. EVIDENCE & REFERENCES¶
| Recommendation | Evidence Level | Source |
|---|---|---|
| IV methylprednisolone accelerates visual recovery but does not change final outcome | Class I, Level A | Beck RW et al. NEJM 1992 (ONTT) |
| Oral prednisone alone (1 mg/kg) increases recurrence rate - avoid as monotherapy | Class I, Level A | Beck RW et al. NEJM 1992 (ONTT) |
| Visual prognosis excellent: 90%+ recover to 20/40 or better by 1 year | Class I | Beck RW et al. Arch Ophthalmol 1993 |
| Brain MRI lesions predict MS: 50% at 15 years with >=1 lesion vs 25% with normal MRI | Class I | Beck RW et al. NEJM 2003 (ONTT 10-year); Optic Neuritis Study Group 2008 (15-year) |
| Cell-based assay (FACS) preferred for AQP4/MOG antibody testing | Class II, Level B | Pittock SJ et al. Neurology 2019; Waters P et al. J Neurol Neurosurg Psychiatry 2014 |
| MOG-IgG associated with better visual recovery and relapsing course | Class II | Jarius S et al. J Neuroinflammation 2018 |
| PLEX beneficial for steroid-refractory demyelinating optic neuritis | Class II, Level B | Roesner S et al. J Neurol 2012 |
| VEP shows prolonged P100 latency in optic neuritis | Class I | Halliday AM et al. Lancet 1972 |
| OCT RNFL thinning correlates with visual outcomes | Class II | Trip SA et al. Brain 2005 |
| Vitamin D deficiency associated with increased MS risk after optic neuritis | Class II | Munger KL et al. JAMA 2006 |
| Smoking increases MS conversion risk after CIS | Class II, Level B | Hedstrom AK et al. Brain 2013 |
CHANGE LOG¶
v1.1 (January 30, 2026)
- Standardized lab tables (1A, 1B, 1C) to Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding format with CPT codes
- Added CPT codes to imaging tables (2A, 2B, 2C)
- Standardized LP studies table with CPT codes and ICU column
- Fixed structured dosing first fields to starting_dose :: route :: frequency :: full_instructions format
- Standardized priority markers from checkmarks to STAT/ROUTINE in patient instructions, lifestyle, and monitoring tables
- Fixed section header formatting to use ## SECTION format
- Fixed 3D table separator formatting
- Added ICD-10 code H46.8
- Added additional clinical synonyms
- Bumped version to 1.1
v1.0 (January 27, 2026) - Initial creation - Comprehensive coverage of typical and atypical optic neuritis - ONTT-based treatment protocol with structured dosing - MS risk stratification based on brain MRI lesions - NMO-IgG and MOG-IgG testing recommendations - Emphasis on oral prednisone monotherapy avoidance - Visual prognosis and monitoring parameters - PubMed citations for all major recommendations
APPENDIX A: Typical vs Atypical Optic Neuritis Features¶
| Feature | Typical (MS-Associated) | Atypical (Consider NMOSD/MOGAD/Other) |
|---|---|---|
| Age | 20-45 years | <15 or >50 years |
| Pain | Present, mild-moderate, worse with eye movement | Absent OR severe |
| Vision loss severity | Mild-moderate (usually >20/200) | Severe (<20/200 or NLP) |
| Laterality | Unilateral | Bilateral simultaneous |
| Disc appearance | Normal (retrobulbar) or mild edema | Marked disc edema, hemorrhages |
| MRI optic nerve | Short segment enhancement | Longitudinally extensive (>50% nerve length) or posterior involvement to chiasm |
| Recovery | Good (>90% to 20/40) | Poor or incomplete |
| Steroid response | Responds then relapses off steroids | Highly steroid-dependent or refractory |
| Brain MRI | White matter lesions (MS pattern) | Normal or atypical lesion pattern |
If ANY atypical features present: Order AQP4-IgG and MOG-IgG testing (Mayo CDS1 Panel preferred)
APPENDIX B: MS Risk Stratification Based on Brain MRI¶
| Brain MRI Finding | 5-Year MS Risk | 15-Year MS Risk | Recommendation |
|---|---|---|---|
| Normal (no lesions) | ~16% | ~25% | Close clinical follow-up; MRI at 3-6 months then annually x 5 years |
| 1-2 lesions | ~37% | ~50% | MS specialist referral; consider early DMT discussion |
| >=3 lesions | ~51% | ~78% | MS specialist referral; strongly consider DMT if McDonald criteria met |
Data from ONTT long-term follow-up studies