Multiple sclerosis in ophthalmology: beyond optic neuritis

Isolated cranial nerve disorder as presenting sign in multiple sclerosis: optic nerve versus "the others"

Background

The prevalence of cranial nerve involvement in Multiple Sclerosis (MS) varies across studies. It has been speculated that first presentation of disease with cranial nerve involvement - except for optic neuritis - may be associated with milder progression.

Aim

This study compares the clinical outcome of patients with MS in a 4-year follow-up of patients with initial symptoms of optic neuritis (ON) versus those with other cranial nerve (OCN) involvement.

Materials and methods

Retrospective analysis of MS patient database of a tertiary referral university MS center. We included treatment-naïve patients diagnosed with MS according to the revised McDonald criteria, who presented with their first clinical symptoms suggestive of ON or OCN. Patients were required to have regular clinical and radiological follow-up visits (at least two outpatient visits per year and one annual 1.5T MRI), and no comorbidities. The number of relapses and the Expanded Disability Status Scale (EDSS) scores were assessed at six-month intervals during clinic visits. The primary outcome was the number of relapses observed during the study period, comparing the ON and OCN groups. Several statistical analyses were performed, including multiple linear regression, Cox proportional hazards model, one-way ANOVA, and odds ratios, to compare the groups.

Results

Of the 84 patients included, none had comorbities (e.g., overlap with other inflammatory diseases, neoplasm etc.). Fifty-five presented with ON and 29 with OCN (e.g., diplopia, trigeminal pain, hearing or vestibular symptoms) at onset. Patients with ON were younger than those with OCN symptoms (p = 0.02), had a higher risk of relapse (more than two relapses) (OR: 1.53) and greater disability (incremental EDSS) over the 4-year follow-up (OR: 1.60).

Conclusion

Patients with OCN involvement at the onset experienced fewer relapses and had better EDSS scores at the 4-year follow-up compared to those with ON at onset. These preliminary findings suggest that MS onset with OCN involvement may be associated with a more favorable disease course.

Uveitis among people with multiple sclerosis: A systematic review and meta-analysis

People with multiple sclerosis (pwMS) encounter numerous ocular complications, including uveitis. MS-related uveitis is linked to diverse complications, encompassing cataracts, cystoid macular edema, band keratopathy, glaucoma, retinal detachment, retinoschisis, vitreous hemorrhage, and occlusive vasculitis. The relationship between uveitis and MS is firmly established, but various prevalence rates have been reported. Hence, we aimed to determine the overall prevalence of uveitis and its different types among pwMS. The systematic search was conducted across PubMed/MEDLINE, Scopus, EMBASE, and Web of Science to identify studies published between January 1, 1990, and November 11, 2023. The meta-analysis was performed using R software version 4.3.3 with a random-effect model to calculate the pooled prevalence with a 95 % confidence interval (CI) of uveitis among pwMS. From a total of 2520 studies reviewed, 12 studies met the inclusion criteria, comprising a total of 54,402 pwMS. Of whom, 72 % were female, and the mean (standard deviation) age was 43.5 (12.1) years. Meta-analysis showed that the pooled prevalence of uveitis among pwMS was 1.1 % (95 % CI: 0.6-1.7 %, I2=95 %, p-heterogeneity<0.01). Moreover, among various uveitis types, intermediate uveitis exhibited the highest prevalence of 0.6 % (95 % CI: 0.2-1.0 %, I2 = 87 %, p-heterogeneity < 0.01) in pwMS. We determined that the prevalence of uveitis among pwMS is 1.1 %. Among different uveitis types, intermediate uveitis stands out as the most prevalent in pwMS. Diagnosing uveitis in pwMS within clinics by specialists is imperative.

Correlations Between Disability Score, Optical Coherence Tomography and Microperimetry in Patients with Multiple Sclerosis

Purpose

To characterize ocular motility disturbances through Microperimetry (MP) in patients with Multiple Sclerosis (MS) trying to detect those capable of influencing the disability to improve the accuracy of assessing visual impact in EDSS scale. MP results were compare with some structural parameters obtained by OCT.

Patients and Methods

Cross-sectional analytical and correlational case-control study approved by Ethical Committee. A total of 82 eyes (41 patients) and 30 healthy eyes (15 subjects) were enrolled after informed consent. All participants underwent ophthalmological evaluation with MP and OCT. Variables included MS disease duration, Expanded Disability Status Scale (EDSS) score; in OCT: central macular thickness (CMT), ganglion cell-inner plexiform layer thickness (GCIPL), and peripapillary retinal nerve fiber layer thickness (pRNFL); and in MP: test duration, reaction time, average macular threshold (AT), and 4 fixation stability indexes (P1, P2, BCEA63, BCEA95).

Results

MS group showed a significant decrease in GCIPL (p < 0.001) and pRNFL thickness (p < 0.001) compared to the control group. Furthermore, patients demonstrated a longer examination (p < 0.001) and reaction (p < 0.001) times, reduced AT (p < 0.001), more unstable fixation indexes (P1 p <0.004, P2 p = 0.018, BCEA63 p = 0.005 and BCEA95 p = 0.007), measured by MP. In addition, patients with a history of ON (n=16) demonstrated longer examination times in MP (p = 0.049) compared to MS patients without ON, but they were not correlations with OCT measurements, EDSS score correlated with the CMT (p = 0.023, r = -0.25), MP duration (p = 0.043, r = 0.22), and fixation indexes (P1 p = 0.049, r = -0.22, BCEA63 p = 0.041, r = 0.23, BCEA95 p = 0.049, r = 0.22).

Conclusion

Our study emphasizes the complementary utility of MP and OCT in assessing MS patients. Additionally, it highlights that using MP for objective measurements of oculomotor dysfunction could improves accuracy in disability assessment on the EDSS scale.

Isolated trochlear nerve palsy: an atypical presentation of multiple sclerosis

A 31-year-old woman presenting with vertical diplopia and history of paresthesia in her hands the previous year was found to have a trochlear nerve palsy. Computed tomography showed no acute intracranial pathology. Magnetic resonance imaging revealed several white matter lesions with a demyelinating pattern. She was diagnosed with relapsing-remitting multiple sclerosis (MS) and started on immunotherapy, with no further exacerbation of MS.

Wall-Eyed Bilateral Internuclear Ophthalmoplegia as an Early Presentation of Multiple Sclerosis

Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) is a rare neuro-ophthalmological condition in which there is ocular motility impairment characterized by bilateral adduction deficiencies, bilateral abducting nystagmus, and exotropia in primary gaze, and is often associated with multiple sclerosis (MS). This report describes a young female who presented with sudden onset of binocular diplopia and alternating exotropia for two days duration, which was associated with a history of intermittent headaches for one year before presenting complaints. Examination revealed alternating exotropia on the primary gaze with bilateral limitation of adduction and bilateral nystagmus on abduction. Other ocular and neurological examinations were unremarkable. Neuroimaging showed multiple white matter lesions that were consistent with demyelinating disease. Her symptoms completely resolved after the initiation of intravenous corticosteroid therapy. However, she developed left upper limb numbness four months later, and a repeat magnetic resonance imaging (MRI) of the brain showed the presence of multiple new brain lesions. Subsequently, she was diagnosed with MS and started on immunotherapy. Her symptoms resolved, with no residual ophthalmoplegia or any neurological symptoms.

Applications of dynamic visual acuity test in clinical ophthalmology

Dynamic visual acuity test (DVAT) plays a key role in the assessment of vestibular function, the visual function of athletes, as well as various ocular diseases. As the visual pathways conducting dynamic and static signals are different, DVATs may have potential advantages over the traditional visual acuity tests commonly used, such as static visual acuity, contrast sensitivity, and static perimetry. Here, we provide a review of commonly applied DVATs and their several uses in clinical ophthalmology. These data indicate that the DVAT has its unique clinical significance in the evaluation of several ocular disorders.