eMedicine Specialties > Ophthalmology > Neurologic Disorders

Multiple Sclerosis: Follow-up

Author: Andrew G Lee, MD, Professor, Departments of Ophthalmology, Neurology and Neurosurgery, University of Iowa Hospitals and Clinics
Coauthor(s): Fiona Costello, MD, FRCP, Assistant Professor, Departments of Ophthalmology and Medicine (Neurology), Neuro-ophthalmologist, Clinical Neurologist and Clinical Investigator, University of Ottawa; Cecil L Berlie, MD, Consulting Staff, Department of Ophthalmology, Luther Midelfort Eye Clinic
Contributor Information and Disclosures

Updated: Jan 26, 2007

Follow-up

In/Out Patient Meds:

  • Methylprednisolone (Solu-Medrol), prednisone taper, and interferon beta therapy can be administered either at home or in a hospital setting. The location of care should be determined by the severity of the patient's condition, as well as by the patient's ability to comply with prescribed health care, present financial status, and other coexisting medical and psychological issues.

Prognosis:

  • The risk of the development of MS after ON is variable in the literature depending on length of follow-up with higher estimates of MS in studies with longer follow-up intervals. An abnormal baseline MRI is the strongest predictor of future development of MS. Five years after the original ONTT, 16% of patients with no plaques on the baseline MRI developed MS. Forty percent of patients with 1 or 2 high-signal densities developed MS, and, of those with more than 2 lesions, 51% developed CDMS over the same period of time. After 10 years of follow-up, after the ONTT, patients who had 1 or more lesions on the baseline MRI had a 56% risk of CDMS, and those patients with no lesions had a 22% risk of future development of MS.
  • Among patients who had no lesions on their baseline MRI, male gender and optic disc swelling were associated with a lower risk of MS, as were the following features: no light perception vision; lack of pain; and fundus findings of severe optic disc edema, peripapillary hemorrhage, or retinal exudates. The strongest predictor for future development of MS was the presence of white matter lesions on an MRI, and this risk was increased with the presence of spinal lesions. Disability from MS has been reported to be less likely in patients who present with ON as their first demyelinating event, few or no MRI lesions, a long period to first relapse, and no disability after the first 5 years of diagnosis.
  • Nevertheless, neither the presence nor the absence of signal abnormalities on the MRI is 100% predictive of whether a patient will develop MS.
  • The size and the location of ON enhancement may be of prognostic significance in ON. Miller et al reported that lesions greater than 1 cm in length or located within the optic canal were associated with a decreased rate and quality of visual recovery. Dunker and Wiegand also reported incomplete recovery in lesions greater than 17.5 mm in length and/or located intracanalicularly.
    • Other predictive factors include a prior history of ON, an early recurrence of ON, early age of onset, a positive family history of MS, an HLA-DR2 tissue haplotype, and northern European ancestry.
    • Male patients who have NLP vision, experience no pain, or have an atypical optic disc appearance (eg, hemorrhages, marked swelling) are less likely to develop MS.
  • Abnormalities in the cerebrospinal fluid (eg, IgG, oligoclonal bands) may be predictive of the development of MS.
  • Various aspects of vision were found to recover differently following resolution of acute ON. One article discussed a study of individuals who experienced ON in either one eye or both (simultaneous) eyes and then recovered vision acuities of 20/30 or better at 6 months. In this study, 85% of 27 patients noted some improved change in the quality of their vision. Objectively, relative afferent pupillary defects (89%) were determined to be the most commonly retained defects, followed by persistent decreased brightness (89%) and altered stereo acuity (80%). Following these changes were disc pallor (77%), depressed contrast sensitivity (72%), dyschromatopsia (57%), and perimetry defects (26%).
  • Visual acuity recovers well in most individuals. Following the ONTT, the 5-year visual outcomes of most of its study patients were assessed. At the time of follow-up, most patients had near normal visual acuity, even if they had a recurrent episode of ON. They found that 87% had visual acuities of 20/25 or better, 7% had visual acuities between 20/25 and 20/40, and 6% had visual acuities worse than 20/50; of the 6%, one half had visual acuities of 20/200 or worse. Findings from the ONTT showed that the visual acuity results obtained did not statistically differ by the type of treatment the patient received, but the rate of recovery did.

Patient Education:

  • Patients should be reassured that most people with ON improve regardless of treatment.
  • Patients, especially those in higher risk populations, should be informed of the relationship between specific monosymptomatic ophthalmologic events (eg, INO, ON) and MS.
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Multiple Sclerosis.

Miscellaneous

Medicolegal Pitfalls

  • The major pitfalls for misdiagnosis of ON are making a diagnosis of ON in a patient with atypical features (eg, older age, progression rather than recovery, marked hemorrhages or exudates) and failing to perform neuroimaging studies, especially in atypical cases (eg, painful acute retrobulbar visual loss with bitemporal hemianopsia in pituitary apoplexy).

Special Concerns

  • The association of MS with ON is a delicate subject that requires a great deal of patient education, reassurance, instruction, and counseling. A formal consultation with a neurologist may be indicated, especially if the referring physician is unable or unwilling to discuss the complex issues surrounding the evaluation, treatment, and prognosis of MS.
 


More on Multiple Sclerosis

Overview: Multiple Sclerosis
Differential Diagnoses & Workup: Multiple Sclerosis
Treatment & Medication: Multiple Sclerosis
Follow-up: Multiple Sclerosis
References
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Further Reading

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Keywords

MS, neurologic disorder, optic neuritis, ON, optic nerve, nystagmus, internuclear ophthalmoplegia, INO

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Contributor Information and Disclosures

Author

Andrew G Lee, MD, Professor, Departments of Ophthalmology, Neurology and Neurosurgery, University of Iowa Hospitals and Clinics
Andrew G Lee, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Academy of Ophthalmology, American Geriatrics Society, North American Neuro-Ophthalmology Society, Pan-American Association of Ophthalmology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Fiona Costello, MD, FRCP, Assistant Professor, Departments of Ophthalmology and Medicine (Neurology), Neuro-ophthalmologist, Clinical Neurologist and Clinical Investigator, University of Ottawa
Fiona Costello, MD, FRCP is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Medical Association, Canadian Medical Protective Association, College of Physicians and Surgeons of Ontario, North American Neuro-Ophthalmology Society, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Cecil L Berlie, MD, Consulting Staff, Department of Ophthalmology, Luther Midelfort Eye Clinic
Cecil L Berlie, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Ralph Garzia, OD, Assistant Dean for Clinical Programs, Associate Professor, School of Optometry, University of Missouri at St Louis
Ralph Garzia, OD is a member of the following medical societies: American Academy of Optometry and American Optometric Association
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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