| Decision #1: Diagnosis |
Both ophthalmologists and neurologists can be equally involved. The diagnosis can be made clinically in the majority of patients (1,2). No ancillary laboratory tests are required if the features of optic neuritis are typical (1,2).
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| Decision # 2: Short-term treatment with steroids |
Both ophthalmologists and neurologists can discuss acute treatment, but some ophthalmologists may consider referral for initiation and completion of treatment. Not treating is a valid option (1,2,13). High dose intravenous steroid treatment can be offered to decrease the duration of symptoms, but has no effect on final visual outcome or long term risk of conversion to clinically definite MS (1,2,13). High dose oral steroids remain of unclear benefit and risk (1). Conventional dose (1mg/kg/day) oral prednisone should not be used (1,2,13).
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| Decision #3: MRI |
Brain MRI with gadolinium should be obtained in all patients to stratify the risk of MS (1,3,24). Ophthalmologists can refer to neurologists for initial and follow up MRI. In some provinces where disease-modifying agent coverage is dependent on meeting the McDonald criteria (24) for the diagnosis of MS, a follow up MRI can be arranged 3 months later in patients with normal baseline MRI. In other provinces where disease-modifying agent coverage is dependent on meeting Poser criteria (25) for the diagnosis of MS, follow up MRI may or may not be arranged.
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| Decision #4:Long-term management |
MS subspecialist neurologists should be involved in decisions regarding long-term treatment with disease-modifying agents. Long term treatment with disease-modifying agents in clinically isolated syndromes remains controversial, but can be recommended in selected patients with abnormal brain MRI (5-9).
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