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Eye Complications Associated With Multiple Sclerosis

Vision problems associated with MS can be frightening, but in many cases they improve over time.

By Ingrid Strauch

Medically Reviewed by Samuel Mackenzie, MD, PhD

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Eye and vision problems are very common among people with multiple sclerosis.
Eye and vision problems are very common among people with multiple sclerosis.
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Eye and vision problems are common among people with multiple sclerosis (MS). They're often the first symptom of MS, but can occur later in the course of the disease as well.

Some of the eye complications associated with MS include optic neuritis, diplopia, nystagmus, and internuclear ophthalmoplegia.

Any of these can occur acutely, as part of a relapse. In many cases, symptoms improve over time, but there can still be lingering aftereffects.

Optic Neuritis

Optic neuritis is caused by inflammation of the optic nerve, which connects the eye to the brain. Symptoms include eye pain, blurred vision, impaired color vision or “graying” of vision, and loss of peripheral vision.

Optic neuritis can arise in one eye at a time or in both eyes simultaneously. It may occur only once in a person’s lifetime or recur many times.

“For acute attacks of optic neuritis, the gold standard for treatment is still IV steroids,” says Scott Newsome, DO, associate professor of neurology at Johns Hopkins Hospital in Baltimore.

Treatment with steroids can speed up recovery by reducing inflammation and dampening the activity of the immune system, but using steroids doesn’t affect how well a person will see after an episode of optic neuritis.

“Ninety percent of people who have optic neuritis go back to high-contrast twenty-twenty vision,” says Dr. Newsome, “but low-contrast visual acuity [sharpness] is impaired, making it difficult to see at dusk.” This can result in difficulty driving, in particular.

In some cases, people who've had optic neuritis continue to have moderately blurred or hazy vision in the affected eye. Occasionally it results in legal blindness (a level of vision loss that's legally defined to determine eligibility for benefits) or even total blindness.

For people who have ongoing difficulty seeing in low light, extra lighting at home and at work, and vision aids — such as magnifiers, special glasses, and computer screen filters — may help to compensate.

After a person has recovered from a bout of optic neuritis, stress or heat can cause temporary visual symptoms that will clear up when the stress is removed or the person cools off. This is called Uhthoff’s phenomenon.

RELATED: What You Need to Know About Optic Neuritis

Diplopia

Diplopia, better known as double vision, most commonly occurs when the eyes aren't aligned and don't point at the same object at the same time. It can have numerous causes.

With MS, misalignment of the eyes is caused by lesions of either the brain stem (the part of the brain that connects to the spinal cord) or the cerebellum (a structure at the back of the brain, just above the brain stem).

The doubling of the image may be side to side, up and down, or a combination of the two, and can vary depending on the visual task, such as reading versus looking at something far away.

For acute symptoms, IV steroids can be tried; if a person doesn’t respond to steroid treatment, doctors may recommend plasmapheresis, in which the liquid portion of the blood (the plasma) is removed and most commonly replaced with albumin or other proteins, according to Newsome.

Once double vision has stabilized, special eyeglasses containing prisms can be used to bring the images seen by one eye into alignment with those seen by the other eye.

If prisms don't work well, strabismus surgery to realign the eyes with one another may be an option.

But, says Newsome, “Many patients will continue to recover from an attack over six months or even a year to a year and a half, so prisms and corrective surgery should not be considered early on.”

Double vision that persists may increase with fatigue and improve with rest.

Nystagmus

In nystagmus, the eyes make fast, repetitive, uncontrolled movements that interfere with vision and depth perception. The eyes may move from side to side or up and down, or they may rotate slightly in one direction and then the other. A person with nystagmus may perceive the world as wiggling, and “it can make people feel sick to their stomach or unbalanced,” says Newsome.

Nystagmus is caused by damage to the nerves and other brain structures that control eye movements. In patients with MS, nystagmus sometimes occurs during a relapse, and may stop as the relapse clears up. For some people, though, the nystagmus still persists.

“This is one of the more challenging things to treat,” says Newsome, who typically uses medication as first-line therapy for the treatment of nystagmus. “There are no surgeries that can treat nystagmus, but vestibular rehab can help with some of the dizziness and balance problems.”

Commonly prescribed drugs used for nystagmus associated with MS include Neurontin and Horizant (gabapentin), baclofen, Namenda (memantine), Klonopin (clonazepam), and Ampyra (dalfampridine).

Some of these are more effective at treating certain types of nystagmus than others (such as vertical versus horizontal, for example), and all of them have potential side effects and may interact with other medications, so be sure to discuss these issues with your physician before you begin taking any of these drugs.

Another possible solution for nystagmus is eyeglasses containing prisms that decrease symptoms by shifting the images the eyes see.

Internuclear Ophthalmoplegia

Internuclear ophthalmoplegia (INO) is characterized by impaired horizontal eye movement.

Symptoms include blurred vision, double vision, dizziness, and a sense of movement when looking at something stationary.

Over the long term, INO can result in double vision and nystagmus.

Like nystagmus, internuclear ophthalmoplegia is caused by damage to brain structures that control eye movements.

In older people, INO is most often caused by a stroke, and usually only affects one eye. But “if a young, otherwise healthy person has it, MS has to be at the top of the list of possible underlying causes,” says Newsome.

When caused by MS, INO typically occurs in both eyes.

For an acute attack, steroids are the first line of treatment. If INO persists, prisms may help, as may the drugs used for nystagmus.

In the case of a person who has never taken any MS-specific medication, “we will put them on a disease-modifying therapy in hopes of preventing future attacks,” says Newsome. “The earlier we can get people on treatment, the better the long-term outcome.”

Seeking Help

If you have any symptoms affecting your eyes or vision, see your doctor. You will likely be referred to an ophthalmologist, neurologist, or neuro-ophthalmologist for an evaluation and, if possible, treatment.

If your vision cannot be restored to normal, ask about vision rehabilitation services to help you learn new ways of doing things in all areas of your life — including at home, at work, and outdoors.

Some specialized MS clinics may offer visual rehabilitation. The American Foundation for the Blind maintains a list of state rehabilitation agencies that can connect you with sources of visual rehabilitation.

The National Multiple Sclerosis Society also keeps a list of organizations to contact for low-vision services and information.

Last Updated:12/7/2016
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Date: 03.12.2018, 07:23 / Views: 41373