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Challenges in Diagnosing Optic Neuritis in MS and MOGAD
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A pair of neurologists provide clinical insight on the difficulties with identifying and differentiating optic neuritis in various autoimmune conditions like multiple sclerosis and neuromyelitis optica spectrum disorder. [WATCH TIME: 4 minutes]
WATCH TIME: 3 minutes
Multiple sclerosis (MS) is a complex, chronic neurological condition that can affect a wide range of systems within the body, including the visual system. The interplay between the eyes and MS is of particular importance, as optic neuritis, a common manifestation, can significantly impact patient outcomes and quality of life. Understanding how MS affects vision and the underlying pathophysiological mechanisms is essential for clinicians to provide timely and accurate diagnoses, as well as to tailor treatment strategies aimed at minimizing visual impairment.
In this 5-episode series, two experienced clinicians from Northwestern University delve into the nuanced relationship between MS and the eyes, offering insights into the latest clinical practices, advancements in drug development, and evolving standards of care. The clinicians, Elena Grebenciucova, MD, and Neena Cherayil, MD, cover a range of topics, including the critical role of neuro-ophthalmologists in the care of MS, the inclusion of the optic nerve to the 2024 McDonald Diagnostic Criteria, the education needed to translate the latest changes to the diagnostic criteria, and the needed research to understand more about the impact of MS on the eyes.
Episode 4 dives into the complexities of diagnosing and managing visual symptoms in MS and related disorders like MOGAD. Grebenciucova, an assistant professor of neurology, and Cherayil, an assistant professor of neurology and ophthalmology, highlight common challenges faced by medical professionals, including recognizing subtle presentations of optic neuritis, the importance of timing and quality in MRI imaging, and distinguishing between visual symptoms caused by migraines versus optic neuritis. Both experts emphasize the vital role of neuro-ophthalmological evaluations and advocate for greater attention to visual impairments in MS care.
Transcript edited for clarity.
Marco Meglio: Are there aspects about optic neuritis or just the eyes and MS that young medical professionals sometimes struggle to understand? Or, you know, do some things look like one thing but may actually be another? Are there any aspects of education that kind of stump people as they come through the ranks?
Neena Cherayil, MD: One thing I'll say for neurologists, generally, is that there are many treatments for visual symptoms associated with MS, like prism glasses for double vision, strabismus surgery, or medications like dalfampridine, which can really help with saccade velocity in patients who have INO, or internuclear ophthalmoplegia. Gabapentin can be used for acquired pendular nystagmus. Oftentimes, neurologists think about spasticity, gait speed, and other kinds of disabilities resulting from MS and other autoimmune diseases but don’t think about the visual system as much, even though it plays a large role in patients’ lives. That’s where a consultation with an ophthalmologist can be really helpful.
Elena Grebenciucova, MD: From my perspective, one of the common challenges I see with neurologists is when a patient presents with non-specific blurriness of vision. Let’s say they come to the emergency department, and the ED documents relatively normal vision, but the patient complains of pain behind the eye and subjective blurriness. They do an MRI—MRI orbits with contrast—and there’s no enhancement. So, a lot of times, people assume, “Well, there’s no optic neuritis, there’s no enhancement on the MRI, and the patient seems okay.” Their vision seems alright on a basic exam.
But I would challenge that because, particularly in MOGAD (myelin oligodendrocyte glycoprotein-associated disorder) or mild optic neuritis, it really depends on the timing of the MRI. Initially, you might not see a lot of enhancement. It also depends on the quality of the MRI. For example, in MOGAD-associated optic neuritis, you can have papillitis, which, on a dilated exam, might look like papilledema. But it’s actually inflammation that’s more anterior, and you may not see the enhancement on MRI.
I just recently had a patient like that in the emergency department. The physicians understandably struggled with what to do, but it was certainly a relapse of MOGAD presenting that way. This is where I call upon ophthalmologists and neuro-ophthalmologists for a good dilated exam, whether in the ED, outpatient, or inpatient settings.
The second common scenario is a person presenting to the ED with a headache and pain behind the eye. Sometimes people with optic neuritis who have blurry vision and pain behind the eye also have a headache. But in headaches, the pain behind the eye or the blurry vision typically lasts for 30 minutes, maybe a couple of hours—not for 24 hours or longer. That’s more typical of a migraine, especially one with visual aura.
In optic neuritis, there can sometimes be confusion. Is it just status migrainosus? In status migrainosus, where a person has a very bad migraine, they should not have blurry vision persisting for 24 hours or longer. If the blurry vision is persistent or worsening for more than several hours, it requires further evaluation. That includes checking visual acuity, doing a dilated exam, and getting an MRI of the orbits with contrast to figure out what’s going on.
It’s not uncommon for me, in the neuroimmunology office, to see patients who say, “When I started having blurry vision, I also had a headache.” In patients with migraines, if you have blurry vision, you might tense up, and that can trigger a migraine. So, we do see that. But if blurry vision persists in the setting of a headache for more than 30 minutes or a couple of hours—and especially if it’s worsening—that needs further workup. It may not be just a migraine.
We do see co-occurrences of optic neuritis and migraine. I’d be very interested to hear Dr. Cherayil’s perspective on this topic and what she sees in her practice.
Neena Cherayil, MD: Yeah, I’d say at least, according to the Optic Neuritis Treatment Trial, the overwhelming majority of patients with optic neuritis presented with eye pain or even just vague periorbital pain or headache-type pain—not the classic “pain on eye movements” that medical students are taught. Certainly, headaches can cause blurry vision, photophobia, or difficulty focusing. But with optic neuritis, it’s the persistent vision loss associated with eye pain that you’re looking for—that should raise suspicion for MS.
