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Friday, October 25, 2013

Ophthalmologic Manifestations of Multiple Sclerosis

Common neuro-ophthalmologic manifestations of multiple sclerosis (MS) are unilateral vision loss due to optic neuritis (ON) and oscillopsia due to nystagmus and diplopia (eg, internuclear ophthalmoplegia [INO], ocular motor palsy). Other common neurologic symptoms are sensory disturbances, motor weakness, and trigeminal neuralgia. Patients with ophthalmic symptoms consistent with a possible MS attack should therefore be questioned about historical features that may be suggestive of MS (eg, prior neurologic deficit, prior diplopia or loss of vision, prior neuroimaging studies).
Diplopia may be due to an INO or an ocular motor cranial neuropathy, typically a sixth nerve palsy; third and fourth cranial neuropathies are uncommon in MS. In an INO, an adduction deficit of the ipsilateral eye is present, with horizontal gaze nystagmus in the contralateral abducting eye. The lesion involves the medial longitudinal fasciculus (MLF). The occurrence of bilateral INO is considered to be highly suggestive of MS, especially in young patients.
A new-onset acquired pendular nystagmus is relatively common, but upbeat, downbeat, convergence-retraction, and other forms of nystagmus may occur as well, depending on the location of the demyelinating lesion.
Combinations of deficits may also occur in MS, including the following:
  • Horizontal or vertical gaze palsies
  • Wall-eyed bilateral INO (WEBINO)
  • Wall-eyed monocular INO (WEMINO)
  • Paralytic pontine exotropia
  • One-and-a-half syndrome
The classic clinical picture of MS is one of multiple neurologic symptoms disseminated in space and time. More specifically, over time, patients manifest episodic neurologic dysfunction due to inflammation in different regions of the central nervous system (CNS).

Special considerations

Patients with ON should be cautioned to avoid work and other activities that may require greater visual skills than they possess. Use of machinery, heavy equipment, or sharp instruments, as well as other visually demanding activities, may have to be avoided until the patient recovers sufficient vision, stereovision, color vision, and contrast acuities.
Patients should know that vigorous physical activity, hot baths, and other activities that raise their core body temperature might result in temporary decreases in vision because of the Uhthoff phenomenon.
Patients with ON, particularly those with abnormal findings on magnetic resonance imaging (MRI), should be offered the opportunity to consult with a neurologist regarding the possibility of MS. A formal consultation with a neurologist is indicated especially if the referring physician is unable or unwilling to discuss the complex issues surrounding the evaluation, treatment, and prognosis of MS.


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