Optic Neuritis in the Era of NMOSD and MOGAD: A Survey of Practice Patterns in Singapore

Abstract

Purpose: The Optic Neuritis Treatment Trial was a landmark study with implications worldwide. In the advent of antibody testing for neuromyelitis optica spectrum disease (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), emerging concepts, such as routine antibody testing and management, remain controversial, resulting mostly from studies in White populations. We evaluate the practice patterns of optic neuritis investigation and management by neuro-ophthalmologists and neurologists in Singapore. Design: 21-question online survey consisting of 4 clinical vignettes. Methods: The survey was sent to all Singapore Medical Council– registered ophthalmologists and neurologists who regularly manage patients with optic neuritis. Results: Forty-two recipients (17 formally trained neuro-ophthalmol-ogists [100% response rate] and 25 neurologists) responded. Participants opted for routine testing of anti–aquaporin-4 antibodies (88.1% in mild optic neuritis and 97.6% in severe optic neuritis). Anti-MOG antibodies were frequently obtained (76.2% in mild and 88.1% in severe optic neuritis). Plasmapheresis was rapidly initiated (85.7%) in cases of nonresponse to intravenous steroids, even before obtaining anti–aquaporin-4 or anti-MOG serology results. In both NMOSD and MOGAD, oral mycophenolate mofetil was the preferred option if chronic immunosuppression was necessary. Steroids were given for a longer duration and tapered more gradually than in idiopathic optic neuritis cases. Conclusions: Serological testing for NMOSD and MOGAD is considered as a routine procedure in cases of optic neuritis in Singapore, possibly due to local epidemiological features of these conditions. Chronic oral immunosuppression is preferred for the long term, but further research is necessary to establish the efficacy and cost-effectiveness of these practices.

A Validated Method to Identify Neuro-Ophthalmologists in a Large Administrative Claims Database

“…To the best of our knowledge, previous studies of neuroophthalmic specialty care have relied primarily on surveys sent to clinicians self-reporting as neuro-ophthalmologists through society directories (e.g., NANOS) (7)(8)(9)(10). This method, although somewhat convenient, is subject to recall and response bias.…”

A Difficult Case of Optic Neuropathy: Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD)

“…Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a recently defined inflammatory demyelinating disease, that generally affects the optic nerve (ON) in adults and the central nervous system in children 1 , 2 . The specific clinical phenotype, radiological findings, and neurological manifestations enable its distinction from other central nervous system inflammatory demyelinating diseases (CNS IDDs) such as aquaporine-4-IgGQ neuromyelitis optica spectrum disorder (NMOSD) and multiple sclerosis (MS) 3 4 5 .…”

“…According to late findings, MOGAD occurs mainly in Caucasians 1 , 6 , 7 , has no typical age of onset, and predominance of gender is still debated 1 , 5 . It is characterized by a high incidence of bilateral cases (24 – 42%) and a greater relapse rate of optic neuritis compared to NMOSD and MS (30 – 64%), as well as a shorter time between relapses 1 , 7 , 8 .…”

The Eye Is a Window to Systemic and Neuro-Ophthalmic Diseases

“…Although MS-related optic neuritis, MOGAD, and NMOSD share significant overlap in their disease presentations, the treatment for these diseases can significantly differ. In this issue, Foo et al 21 present the results of their investigation related to the current approaches to optic neuritis in NMOSD and MOGAD in Singapore, a part of the world where these conditions are not uncommon. 21 Interestingly, serologic testing for NMOSD and MOGAD has recently become in Singapore a routine procedure, adopted by 100% of neuroophthalmologists, irrespective of the clinical or radiological features of the disease.…”

“…In this issue, Foo et al 21 present the results of their investigation related to the current approaches to optic neuritis in NMOSD and MOGAD in Singapore, a part of the world where these conditions are not uncommon. 21 Interestingly, serologic testing for NMOSD and MOGAD has recently become in Singapore a routine procedure, adopted by 100% of neuroophthalmologists, irrespective of the clinical or radiological features of the disease. Similarly, new therapeutic patterns based on immunosuppression seem to emerge in these conditions, both at the acute and chronic stages, requiring however further international consensus, in the future underlying systemic disease process and commencement of appropriate therapies.…”