In linking the neuro-ophthalmologists' increasing role in treatment with improved methods of quantifying our clinical findings, it will be essential that we obtain class 1 evidence with prospective, randomized double-blind clinical trials. To date, we have completed the Optic Neuritis Treatment Trial (ONTT) (32) and the Ischemic Optic Neuropathy Decompression Trial (IONDT) (33). Both studies provided useful information concerning therapy, but perhaps more importantly, they have delineated the natural history of these 2 optic nerve disorders. The ONTT proved that while intravenous corticosteroids might hasten visual recovery early in the clinical course, over a 15-year follow-up period, there was no difference in recovery of visual function between treated and untreated patients. In fact, oral corticosteroids predispose patients to recurrent attacks of optic neuritis. The ONTT also taught us a great deal about the likelihood of a patient developing multiple sclerosis after an episode of optic neuritis and demonstrated that MRI of the brain is a powerful predictor of the chances of developing demyelinating disease. The IONDT proved that optic nerve sheath fenestration was not only efficacious in the treatment of ischemic optic neuropathy but also found that approximately 40% of patients (with visual acuity <20/60) can experience spontaneous improvement.
A third prospective study, the Idiopathic Intracranial Hypertension Treatment Trial is currently underway. Hopefully, it will provide us with a better understanding of the natural history of idiopathic intracranial hypertension and the efficacy of medical therapy.
I see the neuro-ophthalmologists role evolving, not only in our ability to establish the correct diagnosis but also in becoming more involved in the treatment of our patients. But every treatment has a risk–benefit ratio or as I teach my residents: “There is no operation that can't make a patient worse.” We must always be mindful of the guiding principle in medicine: first do no harm.
In conclusion, it is essential that data regarding anatomy, physiology, and psychophysics be obtained in a standardized and quantifiable manner. It is these data that allow us to determine whether our patient's condition is changing and enables us to make better decisions regarding therapy. As neuro-ophthalmologists, we now stand ready to be more involved in patient evaluation, guiding intervention, and being there to assist when intervention is necessary.
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