Skill Checkup: Suboptimally Treated Relapsing-Remitting Multiple Sclerosis (RRMS)

Christopher Luzzio, MD


January 26, 2022

Optic neuritis occurs in up to 50% of patients with MS. Acute to subacute unilateral loss of visual acuity, deficits in color and contrast sensitivity, visual field changes, and pain are common. Moreover, optic neuritis is the first clinical disease manifestation in approximately 20% of patients with MS; in some cases, loss of visual acuity may progress over days or weeks. Periocular pain does not always precede vision loss. As shown in the Optic Neuritis Treatment Trial, loss of visual acuity in patients with optic neuritis is variable and may range from minimal to profound.

Optic neuritis is typically retrobulbar with a normal fundus appearance; mild hyperemia may be noted in the optic disc. The degree of inflammation, changes in visual field, and loss of visual acuity do not correlate well with the appearance of the disc. Loss of visual acuity may also be detected in the asymptomatic eye. A relative afferent pupillary defect is variably present. Central scotoma or any nerve fiber–type defect may occur. Phosphenes lasting from hours to months and sometimes induced by movement or sound may be experienced before, during, or up to several months after recovery from optic neuritis. Flickering scotomas, the Uhthoff phenomenon, and the Pulfrich effect may also occur.

Anterior ischemic optic neuropathy (AION) is characterized by sudden unilateral vision loss. The optic disc appears swollen, with sectorial hemorrhages. Hypertension, hypercholesterolemia, diabetes mellitus, obstructive sleep apnea, and other vascular risk factors are common in patients with AION.

Leber hereditary optic neuropathy (LHON) is characterized by subacute and painless visual loss with central scotoma and poor color vision; over a period of weeks to months, both eyes will be involved. Circumpapillary telangiectasia may be seen on funduscopic examination.


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