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T.D. Myers, J.R. Smith, R.A. Egan, W.T. Shults, J.T. Rosenbaum; Use of Corticosteroid-sparing Systemic Immunosuppression for Treatment of Optic Neuritis not Associated with Demyelinating Disease . Invest. Ophthalmol. Vis. Sci. 2003;44(13):2412.
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Purpose: To study the safety and efficacy of corticosteroid-sparing systemic immunosuppression for corticosteroid-dependent optic neuritis. Methods: Optic neuritis is most often an acute, self-limited inflammation of the optic nerve that resolves over the course of weeks to months with or without corticosteroid therapy. Occasionally, optic neuritis can be chronic and resistant to to corticosteroid taper. We examined records of 10 consecutive patients referred to our tertiary care referral-based North American inflammatory eye disease clinic between 1985 and 2002 with corticosteroid-dependent optic neuritis. Additional published reports of 35 patients with corticosteroid-dependent/resistant optic neuritis treated with systemic immunosuppression were identified using a MEDLINE search. Published reports and patient charts were examined to determine patient demographics, diagnosis, previous therapy and adverse effects, corticosteroid-sparing drug(s), and clinical outcomes including control of inflammation, final corticosteroid dose and complications. Results: The study included 40 women and 5 men: 17 patients with systemic lupus erythematosus, 9 patients with sarcoidosis, 3 with other systemic autoimmune diseases, and 16 with no clinically identifiable systemic association. These patients had recrudescence of symptoms such as decreased vision, pain with eye movement, and poor color vision with attempted taper of corticosteroid. Many of these patients also suffered side effects from systemic corticosteroid use such as weight gain, uncontrolled hyperglycemia, labile mood, and hypertension. Antimetabolites (e.g. methotrexate, azathioprine), cyclosporine, or alkylators (e.g. cyclophosphamide, chlorambucil) were given to enable taper of corticosteroid while effectively controlling optic neuritis. Seventy-eight percent of all patients benefited from use of systemic immunosuppression in that they had successful corticosteroid taper, control of inflammation, improvement in symptoms, and/or tolerance of adverse effects. Twenty-five of 28 (89%) patients on alkylators benefited clinically while only 12 of 28 (43%) patients on antimetabolites had clinical benefit. Mild toxicity was common and 24% of patients, most often those taking cyclophosphamide, discontinued medication because of adverse effects. Conclusions: Systemic immunosuppression is a safe and efficacious alternative to chronic corticosteroid use in cases of corticosteroid-dependent optic neuritis.
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