How Does Multiple Sclerosis Affect The Eyes

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Optic neuritis is an inflammatory demyelination of the optic nerve that is highly associated with multiple sclerosis (MS). Optic neuritis is a presenting feature in up to 20% of MS patients and occurs in up to 50% of MS patients. The condition is more common in women than men and occurs between the ages of 20 and 50. The two most common symptoms of optic neuritis are vision loss and eye pain. Symptoms of optic neuritis include decreased visual acuity, a uniform pupillary defect, abnormal color vision, visual field defects, and low contrast sensitivity. One-third of patients have visible optic nerve inflammation and two-thirds have a normal-appearing optic nerve known as retrobulbar optic neuritis. The Optic Neuritis Treatment Trial (ONTT) showed that high-dose intravenous corticosteroid treatment is beneficial for acute attacks and oral corticosteroids alone are contraindicated due to increased risk of recurrence. Gadolinium contrast-enhanced magnetic resonance imaging (MRI) of the brain and orbit confirms optic neuritis, and baseline MRI findings are an important predictor of future recurrence risk.

How Does Multiple Sclerosis Affect The Eyes

Optic neuritis, multiple sclerosis, inflammatory demyelination, optic neuritis treatment trial (ONTT), Uthoff’s phenomenon, gadolinium contrast-enhanced brain MRI

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Optic neuritis is an acute inflammatory demyelinating injury to the optic nerve. Optic neuritis is a presenting feature in up to 20% of multiple sclerosis (MS) patients and in up to 50% of MS patients at some point during their lifetime. The two most common symptoms of acute optic neuritis are vision loss and eye pain. Optic nerve edema occurs in one-third of MS patients, and two-thirds of patients have a normal optic nerve appearance, known as retrobulbar optic neuritis. Gadolinium contrast-enhanced magnetic resonance imaging (MRI) of the brain and orbit, showing hyperintense white matter abnormalities, is used for diagnosis. In the Optic Neuritis Treatment Trial (ONTT), intravenous corticosteroids accelerated visual recovery and oral corticosteroids alone did not improve visual outcome and were associated with an increased rate of optic neuritis recurrence. Baseline gadolinium contrast-enhanced MRI of the brain and orbit is an essential tool in the diagnosis and management of optic neuritis and serves as a predictor of recurrent episodes. Chronic features of optic neuritis include decreased visual acuity, color discolouration, optic atrophy and visual field loss.

In this case the patient presented to the clinic reporting acute onset of blurred vision, blind spot and halo in the left eye. Although her visual acuity and color vision were normal, she had a new visual field defect and optic nerve swelling in her left eye. The patient was immediately treated with a four-day course of intravenous corticosteroids. At a two-week follow-up examination, her symptoms and visual field defects had resolved. For prompt evaluation and treatment, it is crucial for ophthalmologists to educate patients with a history of MS about the signs and symptoms of optic neuritis.

A 38-year-old Caucasian male presented to the Orlando VA Eye Clinic on October 24, 2017 for a scheduled six-month eye health examination and follow-up of MS with no history of optic neuritis. The patient’s vision has not changed since his previous eye exam on June 22, 2017. He said he still saw blue rings in both eyes two to three times a week and occasionally experienced blurred vision after exercise or a hot shower, which was reported at his last eye exam. The patient’s ocular history included dry eye syndrome OU, form frost keratoconus OD, early cataract OU, retinal degeneration with atrophic retinal hole OU, and MS with no history of optic neuritis. However, the patient experienced signs of blue rings in Uthoff’s vision after overheating or exercise. The patient was diagnosed with MS in 2014, managed by the VA Neurology Clinic. He had a recent brain MRI on June 14, 2017, which was consistent with a clinical impression of MS with the presence of infratentorial and supratentorial lesions. The scan from his previous brain MRI on January 7, 2016 was stable without the development of new lesions. Her systemic medications for MS include dimethyl fumarate (Tecfidera) 240 mg twice daily, aspirin 325 mg once daily, and vitamin D3 1000 IU supplements twice daily. The patient’s systemic health was otherwise unremarkable. Artificial tears were the only eye medication used two to four times a day as needed for dry eye symptoms.

Visual acuity was 20/25 in the right eye, which was stable, and 20/20 in the left eye due to mild keratoconus. Pupils were equal, round and responsive to light with no relative afferent pupillary defect (APD). Confrontational visual field and extraocular motility tests were normal in both eyes. Color vision tested with Farnsworth panel D-15 was normal in each eye. Anterior segment examination showed mild corneal thinning in the right eye but was noncomparable in both eyes. Intraocular pressure was 12 mmHg in each eye. Frontal cortical lenticular changes were present in both eyes. The optic nerves of both eyes were healthy with no edema or pallor; A positive spontaneous venous pulse was present. Optic nerve glial tissue was present in both eyes (Figure 1). The cup-to-disc ratio was 0.35 in the right eye and 0.25 in the left eye. Atrophic perforated peripheral retinal meshes were present in both eyes and were stable from the patient’s previous dilated fundus examination. Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) was performed (Spectralis, Heidelberg Engineering). Compared with age-matched normative data, RNFL was normal in all quadrants and sectors and was stable on scans obtained at the previous visit (Figure 2). Humphrey visual field 24-2 SITA standard testing was performed before pupil dilation and revealed a full field in each eye (Figure 3).

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The patient was informed of stable clinical optic nerve findings with no signs of optic neuritis. He was advised to follow-up with his neurologist scheduled on February 26, 2018 and to return to the eye clinic in six months for follow-up. She was educated about the symptoms of acute optic neuritis and instructed to return to the clinic immediately if any severe eye pain, loss of vision, or other acute changes in vision occurred before her next appointment.

The patient returned to the clinic 10 days later, on November 3, 2017, as an urgent care walk-in reporting the acute onset of blurred vision, blind spots, and halos in the left eye, which had begun the day before. He checked for any vision loss and eye pain associated with his symptoms.

Visual acuity was stable at 20/25 in the right eye and 20/20 in the left eye. Pupils were equal, round and responsive to light without a relative APD. Confrontational visual field and extraocular motility tests were normal in both eyes. There was no pain with eye movements. D15 color vision test was repeated and was normal in each eye. The Humphrey visual field 24-2 SITA standard was completed in the left eye only and showed a new superior cluster of dots appearing as temporal vertical lines from the center (Figure 4). The mean deviation and pattern standard deviation have worsened since the visual field test on October 24, 2017. The mean deviation decreased from -0.28 to -3.96 decibels and the pattern standard deviation increased from 1.07 to 2.22 decibels (Figure 4). Due to time constraints on the day of this urgent care visit, a second visual field examination of the left eye was not completed to determine the repeatability of the new field defect.

Figure 4. Humphrey 24-2 SITA standard visual field test left eye November 3, 2017 (left) compared to October 24, 2017 (right).

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Figure 6. OCT of the retinal nerve fiber layer of the left eye. The thick black line corresponds to the November 3, 2017 scan. The thin gray line corresponds to the baseline scan.

Figure 7. OCT of right and left eye retinal nerve fiber layer. Note the asymmetry of the inferior quadrant and inferior temporal sector showing a thickened retinal nerve fiber layer in the left eye, particularly the 38-micron difference in the inferior temporal sector.

Anterior segment examination was notable for mild corneal thinning in the right eye, which was noted at the patient’s previous visit and was stable. All other anterior segment findings were normal. Intraocular pressure was 11 mmHg in the right eye and 14 mmHg in the left eye. Optic nerve evaluation was unremarkable in the right eye (Figure 5). The left optic nerve showed mild sectoral disc edema with blurring of the disc margin from 6-11 o’clock and associated elevation of the RNFL in the inferior quadrant (Figure 5). The cup-to-disc ratio was 0.35 in the right eye and 0.25 in the left eye. Both optic nerves were pink and showed a spontaneous venous pulse. There was no hemorrhage in either eye. The glial tissue of the left eye inferior to the nasal was previously noted.

OCT of the RNFL of the left eye showed a relative decrease in thickness

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