Egyptian Retina Journal

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 5  |  Issue : 2  |  Page : 32--34

Role of retrobulbar dexamethasone in the treatment of optic neuritis


Sourav Kumar Bose, Gitanjali Bose 
 Nayan Jyoti Eye Care Centre, Kolkata, West Bengal, India

Correspondence Address:
Dr. Sourav Kumar Bose
Nayan Jyoti Eye Care Centre, 9, Jessore Road, Kazipara, Kolkata - 700 028, West Bengal
India

Abstract

Optic neuritis is a disease entity characterized by, as the name clearly suggests, inflammation of the optic nerve. Over many years, the treatment of optic neuritis has been the use of steroids. The Optic Neuritis Treatment Trial laid the foundation stone for calibrating the use of steroids. However, all modalities have their own adverse effects, in terms of cost, patient compliance, adverse effects, etc. The purpose of this article is to evaluate the role of retrobulbar dexamethasone in the treatment of optic neuritis. After proper patient preparation, a neuritic cocktail of dexamethasone and lignocaine, in pretitrated amounts, is injected in the retrobulbar space. This was administered 3 times at an interval of 48 h, followed by oral prednisolone and supplemented with oral Vitamin B complex. Of 14 patients, 8 (57.1%) patients gained to a best-corrected visual acuity (BCVA) of 6/12 or more, 4 (28.5%) patients had BCVA between 6/24 and 6/18, and 2 (14.2%) patients had BCVA of 6/60. Hence, we conclude that such affordable drug combination can provide a cost-effective measure to treat optic neuritis.



How to cite this article:
Bose SK, Bose G. Role of retrobulbar dexamethasone in the treatment of optic neuritis.Egypt Retina J 2018;5:32-34


How to cite this URL:
Bose SK, Bose G. Role of retrobulbar dexamethasone in the treatment of optic neuritis. Egypt Retina J [serial online] 2018 [cited 2019 Mar 20 ];5:32-34
Available from: http://www.egyptretinaj.com/text.asp?2018/5/2/32/252537


Full Text



 Introduction



Optic neuritis is a disease entity characterized by, as the name clearly suggests, inflammation of the optic nerve. It usually affects young adults, especially females aged between 18 and 45 years of age. Although it has been reported from almost all parts of the world, regions with the highest incidence include Northern Europe, Southern Australia, and middle part of North America.[1] Indian studies have shown that multiple sclerosis (MS) constitutes 0.32%–1.58% of neurology admissions in hospitals,[2] and a prevalence of approximately 1.33/100,000 was reported by Singhal et al. in the mid-80s from the west coast of India.

Typical optic neuritis in adults usually presents as acute uniocular visual loss progressing over several hours to days. It may often be associated with ocular pain that worsens on eye movement. The visual acuity may range from 6/6 to perception of light (PL). Bilateral optic neuritis may also occur, either simultaneously or sequentially,[3] which would also be an unusual feature in typical optic neuritis.[4] Whatever may be the presentation, it has a profound effect on the lifestyle of the patient concerned, and hence, a fast and effective treatment must be sought.

 Procedure



The study was conducted on 14 patients, visiting the outdoor of the institute. The presence of MS was ruled out after neurologist consultation. After proper consent, the patients were selected for the treatment. The procedure was performed in the minor operation theater. Lignocaine sensitivity skin test was performed in all patients to exclude those showing anaphylactic reaction. The other exclusion criteria included presence of diabetes, diagnosed demyelinating disease, age <16 years, pregnant women, breastfeeding women, known allergy to any of the drugs used or their components, and coexisting retinal/vitreous disorders.

The “neuritic cocktail” was prepared by mixing 1.5 ml of dexamethasone sodium phosphate (4 mg/ml) and 0.5 ml of lignocaine hydrochloride (20 mg/ml) in a 2 ml disposable syringe, attached to an Atkinson 25-gauge retrobulbar needle. The periocular area around the affected eye was swabbed with 10% povidone-iodine, followed by ethyl alcohol. One drop of 0.5% proparacaine hydrochloride was instilled in the conjunctival sac, followed by two drops of diluted (1:2) 5% povidone-iodine, left in situ for 3 min, and then washed off.

The patient is instructed to lie supine, open his/her eyes, and look upward toward the surgeon, sitting at the head end. The lower fornix is hence better exposed. The needle is inserted at the junction of the lateral one-third and medial two-thirds of the inferior orbital margin by puncturing the forniceal conjunctiva, beveled end facing the globe. As the “give away” sensation is felt and the hub of the needle reaches the orbital margin, confirming that the tip is at the retrobulbar space, the drug is pushed out gradually. After the syringe is empty, it is gently pulled out. When properly administered, the procedure is completely painless and very comfortable. A drop of 0.5% moxifloxacin is instilled in the eye, and the patient is let go.

The cocktail was repeated at an interval of 48 h for 3 such. This was followed by a coarse of oral prednisolone (after breakfast) 20 mg/day for 1 week and then 10 mg/day for 1 week along with oral pantoprazole 40 mg a day before breakfast. During the entire duration of treatment, the patient was also kept on a supplementation of Vitamin B1 + B6 + B12 (100 mg + 100 mg + 5 mg, respectively), which also continued for 1 week more (after stopping oral prednisolone).

All patients were kept in follow-up at 1, 2, and 6 months.

There was a gain in visual acuity of the patient. Of 14 patients, 8 (57.1%) patients gained to a best corrected visual acuity (BCVA) of 6/12 or more, 4 (28.5%) patients had BCVA between 6/24 and 6/18, and 2 (14.2%) patients had BCVA of 6/60. There was no incidence of relapse at the stipulated time.

 Conclusion



Over many years, the treatment of optic neuritis has been the use of steroids. The Optic Neuritis Treatment Trial (ONTT) laid the foundation stone for calibrating the use of steroids.[5] Studies with higher doses of oral corticosteroids (methylprednisolone) versus placebo have been conducted, but no statistically significant benefit could be seen on a long-term basis or in the relapse rate.[6] An observational study evaluated the efficacy and safety profile of intravenous dexamethasone showed that the intravenous pulse dexamethasone led to rapid recovery of vision in acute optic neuritis, without any serious side effects.[7] Intravenous dexamethasone was found to be as effective as high-dose intravenous methylprednisolone therapy, as recommended by the ONTT study.[8] Immunomodulators have also been of proven use in the management of optic neuritis, both myelinating and demyelinating.[9],[10],[11]

Dexamethasone comes at a price of about a sixth of methylprednisolone and even lesser than immunomodulators. Intravenous pulse methylprednisolone and immunomodulators have serious well known adverse effects.[12],[13] Retrobulbar injection of the same ensures avoidance of its side effects, when administered systemically.[14],[15] The procedure takes about 2 min, and the patient can be sent home right after injection. The propensity of intraocular pressure rise with dexamethasone is very less.[16] The only risk loophole of this procedure is the practice of retrobulbar drug injection, which, however, can be avoided by proper administration technique.[17]

The “neuritic cocktail” of retrobulbar dexamethasone with lignocaine followed by oral steroid and Vitamin B supplementation is a fast, effective, and reliable way to restore vision in a patient with demyelinating optic neuritis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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