Visual Outcomes of Plasma Exchange for Acute Optic Neuritis: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the visual outcomes and the efficacy and safety of plasma exchange (PLEX) for the treatment of acute optic neuritis (ON). METHODS: Literature searches without date restrictions and limited to studies published in English were conducted last in January 2025 in the PubMed database. The combined searches yielded 207 citations, 39 of which were reviewed in full text. Of these, 12 articles met the criteria for inclusion in this assessment and subsequently were assigned a level of evidence rating by the panel methodologist. RESULTS: Two studies were rated level II, and 10 studies were rated level III. The 2 level II studies showed improved visual outcomes after PLEX for the treatment of acute ON compared with a comparative or historical cohort of patients treated with corticosteroids alone. The other 10 studies did not have a comparative arm (n = 9) or lacked specific visual acuity outcomes (n = 1) and therefore were rated level III. Ten studies included patients with neuromyelitis optic spectrum disorder ON, all of which found some degree of visual recovery after PLEX. In 8 studies that included other causes of ON, most found improvement in vision after PLEX in patients with multiple sclerosis, myelin oligodendrocyte glycoprotein antibody-associated disease ON, or both, but outcomes for treatment of idiopathic ON were mixed. In the studies that evaluated other causes of ON, most found improvement in vision after PLEX in patients with multiple sclerosis, myelin oligodendrocyte glycoprotein antibody-associated disease ON, or both, but outcomes for treatment of idiopathic ON were mixed. Factors associated with worse visual outcomes included severe vision loss at the time of PLEX, older age, history of prior ON in the affected eye, and delay in PLEX. Major complications were rare and mostly included issues associated with central line placement. CONCLUSIONS: Level II and III evidence suggest that PLEX may be associated with improved visual outcomes in acute ON. Severity of vision loss, older age, prior ON in the affected eye, and delay to PLEX all were associated with less visual recovery. Future randomized clinical trials will be required to confirm level I evidence for the efficacy of PLEX treatment in ON and to help determine the optimal timing for treatment and which patients would be most likely to benefit. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Duke Scholars

Author Mays Antoine Dairi Ophthalmology, Neuro-Ophthalmology