Steroids in Neuro-Ophthalmology

Summary: • Better to refer to steroids as glucocorticoids o Clarifies that we are not using mineralocorticoid effects of steroid o Reminds one of the glucocorticoid-specific side effects • Most common indication for glucocorticoids in neuro-op: giant cell arteritis o Will either use: -Intravenous methylprednisolone -Oral prednisone o Glucocorticoids have both genomic and non-genomic effects -Genomic effects • Involve entry into cell nuclei, altered expression of proteins • Can involve trans-repression or trans-activation of immune system and inflammation • Hours to days to take effect • Reach saturation point quickly with increasing glucocorticoid dosage -Non-genomic effects • Include membrane stabilization • Do not kick in until moderate-to-high glucocorticoid dosage -Want a dose high enough to establish non-genomic effects, but must also sustain it long-term for genomic effects o Choice of glucocorticoid based on both potency and route -Hydrocortisone has a relative potency of 1 -Prednisone and methylprednisolone have relative potency of 4 -Prednisone and methylprednisolone have reduced mineralocorticoid activity -For high glucocorticoid immunosuppressive activity, prednisone and methylprednisolone are preferred drugs for giant cell arteritis • Patient has vision loss -> high dose intravenous methylprednisolone • No vision loss -> high dose oral prednisone • Secondary indications o Include: -Optic neuritis -Neuromyelitis optica -Myelin oligodendrocytic glycoprotein (MOG) o Treatment similar to that for giant cell arteritis -When condition is acute, use "pulse therapy": high levels of intravenous glucocorticoid, typically methylprednisolone -Pulse therapy followed by oral taper with prednisone o Less used indications like traumatic optic neuropathy and non-arteritic anterior ischemic optic neuropathy are controversia