How does MS affect the eyes

After lunch, Jia puts on make up. It is difficult for her to go out, but she insists of making up before she goes out. Her positive attitude is more than just the make up.

A problem with vision is one of the most common symptoms of MS, and often one of the first that people with MS notice. The symptoms can include blurred vision, double vision (diplopia), optic neuritis, involuntary rapid eye movement and occasionally, a total loss of sight.

Problems with vision can result from damage to the optic nerve or from a lack of coordination in the eye muscles. The optic nerve connects the eye to the brain. Inflammation or demyelination in the optic nerve causes optic neuritis, which is experienced as a temporary loss or disturbance in vision and possibly pain behind the affected eye.

Typically, vision returns partially or fully within a few weeks. While it is quite rare for a person with MS to become totally blind, it is not at all uncommon for an individual to have recurrent episodes of optic neuritis over the course of the disease, usually in one eye at a time. Damage to the optic nerve can result in a blurring of vision, which may or may not totally resolve over time. Colour vision requires a great many nerve fibres from the eye for accurate transmission and is particularly susceptible to changes from demyelination.

Jerkiness

Optic neuritis can cause a large, noticeable “blind spot” in the centre of the visual field, and the person experiences a visual image with a dark, blank area in the middle. This is called a central scotoma and is not correctable with either eyeglasses or medication, although steroids may be helpful in the early, acute phase.

Diplopia (double vision), the experience of seeing two of everything, is caused by weakening or incoordination of eye muscles. This symptom is typically treated with a short course of steroids. Patching one eye while trying to drive or read will stop the double image; however, permanent patching of the eye will slow the brain’s remarkable ability to accommodate to the weakness and produce a single image in spite of the weakened muscles. Some physicians are prescribing eyeglasses with special prisms that help to minimise double vision.

Upon examination, the physician may detect a rhythmic jerkiness or bounce in one or both eyes. This relatively common visual finding in MS is nystagmus. Nystagmus does not always cause symptoms of which the person is aware. In the event that it does become troublesome, clonazepan (Klonopin®) is sometimes effective in reducing this annoying but painless problem.

Vision Problems Linked to Multiple Sclerosis

Vision Loss

This happens when the optic nerve which connects the eye to the brain gets inflamed. It is called optic neuritis.

About half of people with MS will have the condition at least once. It’s often the first sign that someone has the disease. But other conditions can cause optic neuritis so it doesn’t always mean that a person has or will get MS.

Symptoms of optic neuritis usually come on suddenly. They include:

  • Blurred vision
  • Graying of vision
  • Blindness in one eye for a short time, especially during an MS flare
  • Pain with eye movement)

It’s rare to get this condition in both eyes at once. Vision loss tends to get worse for a few days before it gets better. The inflammation could last anywhere from 4 to 12 weeks.

If you start to have any symptoms, let your doctor know. IV steroids are generally used to treat the first episode of optic neuritis, but studies suggest that the use of low dose oral steroids may increase the chance of a recurrence. Although the symptoms can be disturbing, the best treatment may be no treatment at all.

Double Vision

This happens when the muscles that control an eye movement are not coordinated because one or more of them not working properly. In MS, the problem occurs in the part of the brain that controls the nerves that go to these muscles. It may be worse when you’re tired or you strain your eyes, so try to rest them throughout the day.

Uncontrolled Eye Movements

People with MS may develop, small, rapid and repetitive eye movements. They may lose control of how they move their eyes up and down or side to side (sometimes described as a quiver). The problem is called nystagmus. It may be mild or it may be severe enough to keep someone from seeing well. Some meds and special eyeglass prisms may ease the condition and improve vision.

Vision problems in MS can range from optic neuritis and blurred vision to double vision (diplopia), involuntary or jerky eye movements (nystagmus) or, on occasion, a total loss of sight. Complete blindness, however, is rare.

Most MS patients experience eye problems at one time or another, and for some they can be a first indication of the disease.

These symptoms generally are caused by damage to the optic nerve, which carries information between the eyes and the brain, or from poor coordination of eye muscles so that the eyes do not move together or move well together.

Optic neuritis, a blurring or graying of vision or blind spot in one eye, results from inflammation in the optic nerve or by damage to myelin (demyelination) along the nerve. Pain and partial vision loss in one eye are common (rarely are both eyes affected), and most people generally recover from an attack.

Double vision and involuntary eye movements (horizontal or vertical) are due to lesions along the nerve pathways that control eye movement. The eyes may be out of alignment, or subject to jerky and uncontrolled movement.

Double vision, or diplopia, results from they eyes not moving together as they should, and can cause a person to see two of whatever object they’re looking at: side by side, one on top of the other, at objects that appear at angles. It may occur only when looking in certain directions, whether straight ahead or off to the side. Double vision can also cause feelings of nausea or vertigo, and affect a person’s balance.

Involuntary eye movement, or nystagmus, is a rhythmic jerkiness or bounce in one or both eyes. It often doesn’t affect vision, and many patients don’t realize they have nystagmus until it’s detected in an examination. But, in some people, these movements can affect vision, with objects appearing to move back and forth, tremble or wiggle (a condition called oscillopsia). Stress, fatigue or heat can aggravate this vision problem, as they can other eye symptoms of MS.

Treating vision problems in MS

Most vision problems eventually improve on their own, but treatments do exist for more severe symptoms.

In optic neuritis, when symptoms are particularly bothersome or affect both eyes — or if a quicker recovery is needed — intravenous steroids, such as methylprednisolone, are usually prescribed.

If double vision is impairing, patching one eye can temporarily be of help as it blocks one of the images. But an eye patch isn’t advised for long-term use as it affects the brain’s ability to correct this problem itself. Eyeglasses with special prisms may also be prescribed, although double vision is usually temporary and will clear on its own. Simply resting the eyes periodically can bring relief.

A few drugs, like clonazepam, gabapentin and baclofen, may be used to ease involuntary and jerky eye movements that are affecting vision, but not everyone is helped by them.

Note: Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

If you have MS, visual symptoms may have been some of the first MS symptoms that you experienced. Your MS diagnosis journey may have begun at a high street optician, having a sight test. The NHS and eye health charities recommend that everyone should have a routine sight test every two years. Many sight problems are treatable if they are picked up early.

At an eye test, an opthamologist or optometrist will check the following:

– Your ability to see detail at a distance (visual acuity).

– How much you can see from the side of your eye when looking straight ahead (field of vision).

– Pressure inside the eyeball, which could indicate glaucoma.

– Changes in the eye which could indicate diabetes or high blood pressure.

– The strength and efficiency of the muscles that hold and move your eyes.

– How your pupils respond to bright light.

– The general health of your retina and lens, and other structures inside the eyeball.

There are some practical things to consider when having an eye test at an optician’s clinic or shop. Manouervring a wheelchair in and around the equipment can be difficult. You may wish to take along someone to help you get into the right positions for the tests, especially if you have problems maintaining an upright posture. If you qualify for free eye tests, then you can also ask to have a home visit sight test, if that would be more convenient due to problems with mobility, cognition, or communication.

If you are unsure whether you qualify for a free eye test, or help with paying for glasses or contact lenses, then you can check the NHS eligibility criteria. Multiple sclerosis is not listed as an automatic qualification for free sight tests, but glaucoma and diabetes are.

Multiple sclerosis

Enroll in the Residents and Fellows contest Enroll in the International Ophthalmologists contest All contributors: Assigned editor: Review: Assigned status Update Pending by Rayna Ungersma on March 4, 2016. Multiple sclerosis Optical coherence tomography (OCT) of the nerve fiber layer from a 42-year-old patient who presented with painful vision loss OS suggestive of optic neuritis. Examination showed temporal pallor of both optic discs. Magnetic resonance imaging showed enhancement of the retrobulbar optic nerve and multiple demyelinating lesions. Cerebrospinal fluid analysis confirmed the diagnosis of multiple sclerosis. OCT on presentation showed thinning of the temporal nerve fiber layer OD and OS suggestive of old optic nerve damage from previously undiagnosed optic neuritis. © 2019 American Academy of Ophthalmology ICD-10

Disease Entity

Multiple sclerosis (MS) is a neurodegenerative disease of the central nervous system (CNS) that results from the immune-mediated inflammation and demyelination of axons. It is characterized by focal demyelinating lesions in the white matter of the brain or spinal cord that vary temporally and spatially, thereby leading to the classic presentation of episodic neurologic symptoms. These symptoms vary depending on the location of lesions, and can include changes in autonomic, motor or sensory functions. Of interest, MS often presents with ocular manifestations secondary to inflammatory demyelination of the visual pathway, and a majority of patients experience at least one episode of ocular involvement in the course of their disease.

Epidemiology

MS affects an estimated 400,000 people in the United States and 2.1 million people worldwide, with a more prevalent geographic distribution among the northern and southern hemispheres. The average age of onset ranges from 15 to 45 years while the average age at diagnosis is 30 years. Females are more commonly affected than males, at a ratio of about 2 to 1.

Etiology

The underlying cause of MS is unknown, though multiple factors have been proposed to contribute to the development and progression of the disease. The leading theories suggest a complex interplay between genetic predisposition and environmental factors.

A genetic component in MS is supported by twin studies showing a concordance rate of 25-30% in monozygotic twins, 5% in dizygotic twins, and 3% in non-twin siblings. In addition, a number of genome-wide association studies have identified more than 100 risk loci in MS, and a majority of these genes have been found to encode for proteins involved in immune modulation. Although polymorphisms in the human leukocyte antigen (HLA) have been identified as the strongest susceptibility loci, other non-HLA genes have also been found.

Despite data suggesting significant genetic influence in MS, genes alone do not fully contribute to the development of the disease. A number of environmental factors such as infection, location, climate, stress, occupation and diet have been postulated to be involved. There is evidence suggesting the development or exacerbation of MS following post-viral syndromes, such as those from Epstein-Barr virus (EBV) and human herpes virus (HHV). The geographic variation of MS further supports an environmental role. Although the underlying cause remains unclear, factors such as decreased sun exposure and low levels of vitamin D have been proposed to explain the latitudinal gradient.

Pathophysiology

MS is thought to be an autoimmune disease and this theory is supported by its shared characteristics with other autoimmune disorders. These features include the predominance of women affected, the association with HLA polymorphisms, and the presence of autoantibodies to myelin antigens in CSF.

The chronic inflammation, degeneration and demyelination of axons in the CNS lead to the clinical presentation of neurologic dysfunction. The inflammatory process is mediated by T lymphocytes that recognize myelin as a foreign entity and trigger other immune cells, macrophages, cytokines and antibodies that together lead to myelin and axonal breakdown. These T cells are thought to gain entry into the brain from disruptions in the blood-brain barrier, which can result from post-viral infections. With the loss of myelin, the protective and insulating fatty sheath that surrounds axons, the conduction of electrical impulses is compromised.

This impaired transmission of neurologic signal can occur anywhere within the CNS, including the visual system. Ophthalmic involvement can be categorized into lesions of the afferent or efferent visual pathways. The afferent pathway is responsible for the transmission of sensory information from the retina to the brain. The optic nerve is most commonly involved and leads to a number of visual symptoms, described below. Infrequently, the optic chiasm and optic tracts are involved which lead to visual field defects such as bitemporal hemianopsia and homonymous hemianopsia, respectively.

The efferent pathway is responsible for motor output to the pupillary muscles and extraocular muscles. Disorders of ocular movement affect more than 40% of patients with MS. Lesions can involve the brainstem, cerebellum or cranial nerves and result in ocular misalignment and symptoms of oscillopsia, nystagmus and diplopia. A condition termed internuclear ophthalmoplegia (INO) occurs with lesions in the medial longitudinal fasciculus (MLF), a highly myelinated tract between the paramedian pontine reticular formation (PPRF) of the abducting eye to the oculomotor nucleus of the contralateral adducting eye. This facilitates synchronous lateral gaze. Therefore, MLF lesions result in impaired conjugate adduction as well as nystagmus of the abducting eye.

Diagnosis

Demographic information such as age, sex, race, country of origin and migration status is relevant as MS is more common in women ages 15-45 who are from areas of northern or southern hemispheres. Family history of MS is also relevant as there is a genetic predisposition to the disease. Recent stressors, viral infections, and the presence of sick contacts should also be explored.

MS is classically described as a condition in which neurologic symptoms vary in time and space. Because demyelination can have diffuse involvement within the CNS, patients often complain of a constellation of seemingly unrelated symptoms. In 75% of patients, the initial presentation of MS involves an isolated complaint—45% are motor or sensory and 20% are visual. Therefore, a thorough review of systems is crucial, and should involve questions about loss of sensation, muscle weakness, pain, headaches, vision changes, impaired cognition, depression, and loss of bowel, bladder or sexual function.

It is equally important to elicit the onset, duration and temporal relationship of symptoms. Exacerbations or “flare-ups” can be acute or subacute in onset and typically last days to months. These episodes are usually transient, with improvement or even complete resolution of symptoms in 85% of cases. However, symptoms can worsen or become permanent in the remaining 10-15% of those affected.

Physical examination

The neurologic exam can provide useful information regarding localization of the lesion(s), as well as severity and extent of involvement. The exam consists of the evaluation of cranial nerves, deep tendon reflexes, motor strength, sensation, gait, balance and coordination.

The ophthalmic examination should begin with inspection of the eyes for external ocular findings, range of extraocular muscle movement, pupillary changes, and erythema or inflammation. A slit lamp examination is important for visualization of internal eye structures, notably the optic disc. Other components of the ophthalmic exam involve tests for visual acuity, color vision, contrast sensitivity, afferent pupillary defects and visual field defects. In addition, the use of optical coherence tomography (OCT) and visual evoked responses (VER) can provide information about the extent of involvement and allow for quantitative measures for disease progression over time.

Signs and Symptoms

Neurologic signs and symptoms of MS can be autonomic, visual, motor or sensory. Changes in sensation can present as pain, numbness, tingling, or pins and needles sensation. Motor involvement manifests as muscle weakness, muscle spasms, impaired coordination and balance or difficulty with speech and swallowing. Autonomic symptoms include bowel dysfunction (diarrhea or constipation) and bladder dysfunction (urinary incontinence). Cognitive complaints in MS include fatigue, decreased attention span, concentration, memory, and judgment. Psychological symptoms include depression and mood instability. MS is associated with other clinical findings such as: Charcot triad of dysarthria, ataxia, and tremor; Uhthoff’s phenomenon of worsening of symptoms in higher temperatures; Lhermitte’s sign of an electrical sensation running down the back when the neck is flexed; and trigeminal neuralgia presenting as facial pain or weakness.

Ocular manifestations are common in MS. Up to 20% of patients have optic neuritis as the initial clinical presentation and 75% of patients have at least one episode throughout the course of their lives. Optic neuritis associated with MS typically presents as a monocular painful vision loss that occurs over hours to days and lasts a few weeks. Changes in visual acuity can range from mild to severe; 10% of patients are 20/20, 25% are 20/30-20/40, 29% are 20/50-20/190 and 36% are 20/200 or worse. Orbital pain occurs in 92% of patients and is usually worse with extraocular movement. Patients will also present with diminished color vision (dyschromatopsia in 88%, best assessed by red desaturation), diminished contrast sensitivity, visual field loss (most commonly central scotoma) and a relative afferent pupillary defect (RAPD). Slit lamp examination will reveal optic disc swelling in one-third of patients. Papillitis is more common in postviral and infectious neuritis than demyelinating neuritis, but considerable overlap exists. Retinal nerve fiber layer (RNFL) thinning reflecting axonal damage is observed in about 70% of patients with acute optic neuritis, while visual evoked potential (VEP) increases in latency and decreases in amplitude are found in 65%.

Internuclear ophthalmoplegia occurs in about 30% of patients. This condition presents with diplopia, nystagmus, and loss of depth perception (stereopsis) secondary to an adduction deficit or adduction lag on conjugate gaze. Other patterns of ocular misalignment include skew deviation, gaze paresis and impaired smooth pursuit. Uveitis can occur in 1-2% of patients with MS, a rate that is 10 times more common than that of the general population. Symptoms of uveitis include pain, photophobia, and conjunctival injection.

Clinical diagnosis

The 2010 revised McDonald Criteria is widely used for the clinical diagnosis of MS. The criteria include the presence of two or more attacks involving two or more clinical lesions; two or more attacks of one clinical lesion with evidence for dissemination in space as demonstrated by MRI or CSF; one attack involving two or more lesions demonstrated by MRI or followed by a second attack; one attack of one lesion demonstrated by MRI, CSF or followed by a second attack. An attack is defined as any subjective or objective neurologic disturbance of 24-hour duration occurring 30 days apart, in the absence of fever or infection. MS is classified into four subtypes depending on its clinical course: relapsing-remitting (RRMS), secondary progressive (SPMS), primary progressive (PPMS), and progressive relapsing (PRMS).

Diagnostic procedures

Repeated episodes of demyelination result in the formation of plaques that are seen as hyperintense T2 lesions or post-gadolinium enhancement on magnetic resonance imaging (MRI). MRI of the head and spine is performed to evaluate for these demyelinating plaques in the periventricular, juxtacortical, infratentorial or spinal cord white matter. Optic neuritis in MS is typically seen as a unilateral T2 lesion of the optic nerve. Serial imaging is useful for comparing episodes and monitoring disease progression.

Laboratory test

Lumbar punctures can be performed for evaluation of the CSF for oliclonal bands and intrathecal immunoglobulin G (IgG). In an atypical presentation of optic neuritis, suspicion for a non-MS cause should prompt additional laboratory testing. Atypical features include bilaterality, painless vision loss, lack of characteristic MRI findings, lack of response to corticosteroids, and presence of severe optic nerve head swelling or peripapillary hemorrhages. The following laboratory tests should be considered given a patient’s history, risk factors and clinical findings:

  • Antinuclear antibody (ANA) for systemic lupus erythematosus
  • Angiotensin-converting enzyme (ACE) and lysozyme for sarcoidosis
  • Venereal Disease Research Laboratories , rapid plasma reagin and fluorescent treponemal antibody (FTA-ABS) for syphilis
  • Anti-aquaporin 4 IgG antibody for neuromyelitis optica (NMO)
  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for inflammatory disorders
  • Tuberculin skin test, chest x-ray or Quantiferon-TB for tuberculosis
  • Lyme titers for Lyme disease (in an endemic area)

Differential diagnosis

The differential diagnosis for optic neuritis is broad, and accurate assessment is important for the proper treatment of the underlying etiology. They include:

  • Inflammatory conditions: NMO or Devic’s disease, acute disseminated encephalomyelitis (ADEM), sarcoidosis
  • Infections: Tuberculosis, Syphilis, Lyme and Bartonella
  • Compressive lesions: orbital tumors or aneurysms
  • Connective tissue or vascular diseases: lupus, granulomatosis with polyangiitis, Sjogrens, Behcet
  • Nonarteritic anterior ischemic optic neuropathy (NAION)
  • Severe systemic hypertension
  • Acute papilledema from increased intracranial pressure
  • Leber’s hereditary optic neuropathy (LHON)
  • Optic nerve glioma
  • Toxic or metabolic optic neuropathy: alcohol, malnutrition, ethambutol, heavy metals
  • Central serous retinopathy or other maculopathies

Management

There is no cure for MS. Management involves pharmacotherapy for immune modulation and symptomatic relief. The Optic Neuritis Treatment Trial (ONTT) has shown that high-dose intravenous methylprednisone improves recovery time for visual function, contrast sensitivity and color vision. However, corticosteroids have not been shown to improve final visual outcomes. Intravenous immunoglobulin (IVIg) has not been shown to improve long-term visual acuity, contrast sensitivity or color vision.Plasmapheresis may be used short term for severe attacks if steroids are contraindicated or ineffective. Interfeon-beta and glatiramer acetate are generally used as first-line disease-modifying agents in MS, with relapse reduction rates of 18-34% in some trials. Other FDA-approved disease-modifying drugs include fingolimod, teriflunomide, dimethyl fumarate, natalizumab and alemtuzumab.

Prognosis

Multiple sclerosis can have severe debilitating effects within 20-25 years of onset. Up to 30% of patients eventually require assistance for ambulation, and 22% become wheelchair bound. There is a 5 to 10 year decrease in life expectancy, and death secondary to cardiovascular disease, infection and suicide is higher in MS compared to the general population.

Many of the clinical findings of optic neuritis come from the Optic Neuritis Treatment Trial (ONTT), a multi-institutional study of 454 patients with acute unilateral optic neuritis carried out between 1988 and 1991. The 15-year follow-up of the Optic Neuritis Treatment Trial (ONTT) showed that clinically definite MS developed in 50% of ONTT patients in 15 years. However, the probability of developing clinically definite MS based on MRI scan appearance ranged from 25% for patients with no lesions on the brain MRI to 72% with 1 or more lesions.

Visual prognosis following the first episode of optic neuritis is typically good with or without the use of corticosteroids. Visual symptoms such as decreased visual acuity, visual field defects, and color vision defects recover within weeks to months. A majority of patients achieve 20/20 vision one year after an acute episode while 8% of patients retain a visual acuity worse than 20/40. However, recurrent episodes are associated with less favorable prognosis.

  1. American Academy of Ophthalmology. OCT of the nerve fiber layer. https://www.aao.org/image/oct-of-nerve-fiber-layer Accessed July 31, 2019.
  2. 2.0 2.1 Simpson S Jr., Blizzard L, Otahal P, et al. Latitude is significantly associated with the prevalence of multiple sclerosis: A meta-analysis. J Neurol Neurosurg Psychiatry 2011; 82: 1132–1141.
  3. World Health Organization (2008). Atlas: Multiple Sclerosis Resources in the World 2008 (PDF). Geneva: World Health Organization. Pp. 15–16. ISBN 92-4-156375-3
  4. Willer CJ, Dyment DA, Risch NJ, Sadovnick AD, Ebers GC; Twin concordance and sibling recurrence rates in multiple sclerosis. Canadian Collaborative Study Group. Proc Natl Acad Sci U S A. 2003 Oct 28;100(22):12877-82.
  5. Bashinskaya VV, Kulakova OG, Boyko AN, Favorov AV, Favorova OO. A review of genome-wide association studies for multiple sclerosis: classical and hypothesis-driven approaches. Hum Genet. 2015 Nov;134(11-12):1143-62.
  6. Bahreini SA, Jabalameli MR, Saadatnia M, Zahednasab H. The role of non-HLA single nucleotide polymorphisms in multiple sclerosis susceptibility. J Neuroimmunol. 2010 Dec 15;229(1-2):5-15.
  7. 7.0 7.1 Marrie RA. Environmental risk factors in multiple sclerosis aetiology. Lancet Neurol. 2004 Dec;3(12):709-18.
  8. Banwell B, Bar-Or A, Arnold DL, et al. Clinical, environmental, and genetic determinants of multiple sclerosis in children with acute demyelination: a prospective national cohort study. Lancet Neurol 2011; 10: 436–445.
  9. Soldan SS, Berti R, Salem N, Secchiero P, Flamand L, Calabresi PA, Brennan MB, Maloni HW, McFarland HF, Lin HC, Patnaik M, Jacobson S. Association of human herpes virus 6 (HHV-6) with multiple sclerosis: increased IgM response to HHV-6 early antigen and detection of serum HHV-6 DNA. Nat Med. 1997 Dec;3(12):1394-7.
  10. Pender MP. CD8+ T-cell deficiency, Epstein-Barr virus infection, vitamin D deficiency, and steps to autoimmunity: A unifying hypothesis. Autoimmun Dis 2012; 2012: 189-96.
  11. Prasad S, Galetta SL. Eye movement abnormalities in multiple sclerosis. Neurol Clin. 2010 Aug. 28(3): 641-55.
  12. Tsang BK, Macdonell R. “Multiple sclerosis- diagnosis, management and prognosis”. Australian family physician Dec 2011. 40 (12): 948–55.
  13. Milo R, Kahana E. Multiple sclerosis: geoepidemiology, genetics and the environment. Autoimmun Rev Mar 2010. (5): A387–94.
  14. Miller D, Barkhof F, Montalban X, Thompson A, Filippi M. Clinically isolated syndromes suggestive of multiple sclerosis, part I: natural history, pathogenesis, diagnosis, and prognosis. Lancet Neurol. 2005 May. 4(5):281-8.
  15. 15.0 15.1 The clinical profile of optic neuritis. Experience of the Optic Neuritis Treatment Trial. Optic Neuritis Study Group. Arch. Ophthalmol. 1991. 109(12),1673–1678.
  16. Costello F, Burton JM. An approach to optic neuritis: the initial presentation. Expert Rev Ophthalmol. 2013. 8(6):539–551.
  17. Costello F. The afferent visual pathway: designing a structural-functional paradigm of multiple sclerosis. ISRN Neurol. 2013. 2013:134858.
  18. Müri RM, Meienberg O. The clinical spectrum of internuclear ophthalmoplegia in multiple sclerosis. Arch Neurol 1985; 42:851.
  19. Amezcua M, Morrow MJ Jirawuthiworavong, G. Current Opinion in Ophthalmology Nov 2015. 2(6): 534-539.
  20. McClelland C, Galetta S. Eye Symptoms, Signs, and Therapy in Multiple Sclerosis. Rae-Grant A, Fox R, Bethoux F. Multiple Sclerosis and Related Disorders: Diagnosis, Medical Management, and Rehabilitation. Demos Medical Publishing; 2013. 179-86.
  21. Polman C et al. Diagnostic criteria for multiple sclerosis: 2010 Revisions to the McDonald criteria. Annals of Neurology. 2011;69:292-302.
  22. Gaier ED, Boudreault K, Rizzo JF 3rd, Falardeau J, Cestari DM. Atypical Optic Neuritis. Curr Neurol Neurosci Rep. Dec 2015; 15(12):76.
  23. Kaiser PK. Friedman NJ. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. 4th Edition. 2014.
  24. Costello F. Inflammatory optic neuropathies. Continuum (Minneap Minn). Neuro-ophthalmolog. Aug 2014; 20(4): 816-37.
  25. Beck RW, Cleary PA, Anderson MM Jr, Keltner JL, Shults WT, Kaufman DI. A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. The Optic Neuritis Study Group. N Engl J Med. Feb 1992. 326(9):581-8.
  26. Roed et al. A double-blind, randomized trial of IV immunoglobulin treatment in acute optic neuritis. Neurology Mar 2005; 64(5): 804-810.
  27. Ruprecht K, Klinker E, Dintelmann T, Rieckmann P, Gold R. Plasma exchange for severe optic neuritis: treatment of 10 patients. Neurology 2004. 63(6): 1081–1083.
  28. Scott LJ. Glatiramer acetate: a review of its use in patients with relapsing-remitting multiple sclerosis and in delaying the onset of clinically definite multiple sclerosis. CNS Drugs 2013; 27:971–988.
  29. Swingler RJ, Compston DA. The morbidity of multiple sclerosis. Q J Med. Apr 1992; 83(300):325-37.
  30. Manouchehrinia A, Tanasescu R, Tench CR, Constantinescu CS. Mortality in multiple sclerosis: meta-analysis of standardized mortality ratios. J Neurol Neurosurg Psychiatry. Mar 2016; 87(3):324-31.
  31. Beck RW, Cleary PA, Backlund JC. The course of visual recovery after optic neuritis. Experience of the optic neuritis treatment trial. Ophthalmology. 1994; 101(11):1771-8.

CMSC INforMS: Multiple sclerosis eye problems: Optic neuritis, nystagmus and diplopia

Tuesday, January 5, 2016
Posted by: Elizabeth Porco
Share |

Multiple sclerosis (MS) can lead to many health complications including eye problems like optic neuritis, nystagmus and diplopia. Multiple sclerosis is a disease which causes nerve damage along the spinal cord and in the brain. Multiple sclerosis can affect each patient differently but at some point a multiple sclerosis patient will experience some type of visual or eye problem.

Many multiple sclerosis diagnosis is done based on an eye problem. When MS flares up it can lead to optic nerve damage resulting in blurry vision, loss of normal color vision, depth perception problems, and seeing dark spots in your line of vision. In many cases patients will regain their sight but in others their vision may become reduced.

Optic neuritis: Symptoms, causes and risks

Optic neuritis is a condition of blurry or hazy vision which only affects one eye. Eye pain or discomfort may occur in optic neuritis, more so when the eye moves. The cause of optic neuritis isn’t well understood and many cases are deemed idiopathic meaning no identifiable cause is found. In multiple sclerosis optic neuritis is common and is often the first symptom of MS. Infections, too, can lead to optic neuritis.

Common symptoms of optic neuritis are:

  • Vision loss in one eye – this is temporary and can last seven to 10 days
  • Periocular pain – when pain worsens when the eye moves
  • Dyschromatopsia – inability to see colors correctly
  • Photopsias – seeing flashing lights
  • Changes to how the pupil reacts to light
  • Uhthoff’s phenomenon – vision worsens with an increase in body temperature

Risk factors for optic neuritis include:

  • Being female between the ages 18 to 45
  • Having a diagnosis of multiple sclerosis
  • Living in a high latitude

Nystagmus/uncontrolled eye movements

When the eye moves uncontrollably either side to side or up and down this is referred to as nystagmus. In multiple sclerosis patients they may not even be aware that they have nystagmus as the eye movement does not interfere or impair their vision. In some cases though vision may become affected where patients feel as if objects are moving which is referred to as oscillopsia.

There are medications which can be prescribed in order to control nystagmus but it’s important to note that these medications do not work for everyone. As continued research is conducted we move closer to possible finding better treatments for nystagmus.

Diplopia/double vision

Another common multiple sclerosis-related eye problem is diplopia, or double vision. In diplopia a single object may appear as two because the eyes are not working properly together. Often double vision may only occur when looking at objects in a certain way, for example it may only occur if you’re looking straight ahead or to one side.

Some side effects of double vision are that a person may feel nauseous, experience vertigo or experience a lack of coordination and even have an increase in falls.

Double vision, or diplopia, often will go away on its own but the use of steroids or drop tablets may help speed up recovery. If double vision is particularly bothersome you can wear a patch on one eye in order to help you see clearer or wear glasses fitted with special prisms to realign double images.

Treatment of vision problems in MS

Many of the vision problems associated with multiple sclerosis will resolve on their own which means no treatment is required. Even though vision problems can resolve on their own they may be reoccurring with MS relapses.

Your doctor may prescribe IV and oral corticosteroids to treat specific vision problems associated with multiple sclerosis. As mention eye patches or prism glasses may be recommended in order to treat double vision.

It’s also important to avoid triggers for vision problems which can be stress, fatigue, or even overuse of the eyes. High temperatures, too, should be avoided as it can contribute to optic neuritis.

If you have multiple sclerosis and are concerned about your vision it’s best to speak with your doctor in order to determine the best mode of treatment.

By: Bel Marra Health | Brain FunctionEye Health

  • CMSC Disclaimer
    The industry news information and articles are for informational purposes only, and are not intended to represent any trends, partnerships, commitments, or research of the Consortium of MS Centers or any of it’s members in any way whatsoever, nor should any party be libel in any way to the reader or to any other person, firm or corporation reading this industry news section. Although the CMSC site includes links providing direct access to other Internet sites, CMSC takes no responsibility for the content or information contained on those other sites, and does not exert any editorial or other control over those other sites. CMSC is providing information and services on the Internet as a benefit and service in furtherance of CMSC’s nonprofit and tax-exempt status. CMSC makes no representations about the suitability of this information and these services for any purpose.

Coping with Multiple Sclerosis Vision Disturbances

For individuals with MS, vision problems may come and go. They may affect just one eye or both. The problems may grow worse and then disappear, or they may stick around.

Understanding what types of visual disturbances you may experience can help you prepare for living with them if they become permanent.

Common visual disturbances caused by MS include:

Optic neuritis

Optic neuritis causes blurry or hazy vision in one eye. This effect might be described as a smudge in your field of vision. You may also experience mild pain or discomfort, especially when moving your eye. The greatest visual disturbance will likely be in the center of your field of vision but may also cause trouble seeing to the side. Colors may not be as vivid as normal.

Optic neuritis develops when MS begins to break down the protective coating surrounding your optic nerve. This process is called demyelination. As MS grows worse, demyelination will become more widespread and chronic. That often means the symptoms will grow worse and your body may not return entirely to normal once the symptoms disappear.

According to the Multiple Sclerosis Trust, 70 percent of people with MS will experience optic neuritis at least once during the course of the disease. For some people, optic neuritis may even be their first symptom of MS.

The symptoms of pain and blurred vision may get worse for up to two weeks, and then begin to improve.

Most people have normal vision within two to six months of an acute episode of optic neuritis. African-Americans usually experience more severe vision loss, with one study showing only 61 percent vision recovery after one year. By comparison, 92 percent of Caucasians recovered their vision. A different study found that the more severe the attack, the poorer the outcome.

Diplopia (double vision)

In normally functioning eyes, each eye will transmit the same information to the brain for it to interpret and develop into an image. Diplopia, or double vision, occurs when the eyes send two images to your brain. This confuses your brain and can cause you to see double.

Diplopia is common once MS begins to affect the brainstem. The brainstem helps coordinate eye movement, so any damage to it may result in mixed signals to the eyes.

Diplopia can resolve completely and spontaneously, though progressive MS can lead to persistent double vision.

Nystagmus

Nystagmus is an involuntary movement of the eyes. The movement is often rhythmic and results in a jerking or jumping sensation in the eye. You may experience dizziness and nausea as a result of these uncontrolled movements.

Oscillopsia, a feeling that the world is swaying from side to side or up and down, is also common in people with MS.

This type of visual disturbance is often caused by an MS attack affecting the inner ear or on the cerebellum, the brain’s coordination center. Some people only experience it when looking in one direction. The symptoms may get worse with certain activities.

Nystagmus typically occurs as a chronic symptom of MS or during a relapse. Treatment can help repair your vision and sense of balance.

Blindness

As MS grows more severe, so will the symptoms. This includes your vision. People with MS may experience blindness, whether partial or full. Advanced demyelination can destroy your optic nerve or other parts of your body responsible for vision. This can permanently affect eyesight.

Vision Problems 

How can MS affect my eyes?

MS is a disease of the central nervous system (CNS), which includes the optic nerve—the nerve that transmits light and visual images to the brain.

  1. Optic Neuritis
    An inflammation of the optic nerve that can cause a sudden loss of vision, usually in 1 eye; blurred vision; and eye pain. Optic neuritis is the most common MS-related vision problem. Approximately half of people with MS will have at least 1 episode of optic neuritis. Frequently, it is the first symptom of MS. Optic neuritis may result in blurring or graying of vision, or rarely, blindness in 1 eye. A dark spot may also occur in the center of the visual field.
  2. Nystagmus
    Uncontrolled horizontal or vertical eye movement is another common symptom that impacts vision. Nystagmus may be mild, occurring only when the person looks to the side. Sometimes, it may be severe enough to impair vision.
  3. Diplopia
    Occurs when the pair of muscles that control a particular eye movement are weak. The muscles then become uncoordinated. When the images are not properly fused, the person sees a double image. Double vision may increase with fatigue or overuse of the eyes.

About the author

Leave a Reply

Your email address will not be published. Required fields are marked *