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Educating the Clinical Community on Changes to MS Diagnostic Criteria
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In this third episode, experts delve into the evolving role of optic neuritis and the central vein sign in refining multiple sclerosis diagnosis, highlighting their significance in distinguishing MS from other conditions and ensuring accurate patient care. [WATCH TIME: 3 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.
In episode 3, the duo discusses the education clinicians need to safely and effectively apply the latest changes of the diagnostic criteria. Specifically, they talk about the integration of optic neuritis and the central vein sign into the revised MS diagnostic criteria, highlighting the need for targeted education and clinical understanding. Grebenciucova, an assistant professor of neurology, and Cherayil, an assistant professor of neurology and ophthalmology, delve into the significance of distinguishing MS-related optic neuritis from mimicking conditions like NMOSD and MOGAD, emphasizing the role of specific testing, such as antibody assays and imaging techniques, in achieving accurate diagnoses.
Transcript edited for clarity.
Marco Meglio: With these new diagnostic criteria, there’s a bit of an adjustment period, per se, and clinicians are obviously going to need to learn a little more about these criteria and how to apply them correctly. From an educational perspective, what types of education are needed to address the eye-related aspects of this? Specifically, how do we integrate the optic intricacies that are now part of the new diagnostic criteria?
Elena Grebenciucova, MD: From my perspective, of course, we’re waiting for the official publication so it becomes accessible to everyone. But certainly, CME programs need to be developed to provide a focused review of how these criteria affect diagnosis. This would also help avoid confusion, because when diagnostic criteria expand, it tends to create some uncertainty. Specifically, when it comes to optic neuritis, it would be very beneficial to create CME programs dedicated to understanding how incorporating optic neuritis into the diagnostic criteria impacts early diagnosis. These programs could also focus on differentiating optic neuritis from other autoimmune conditions that mimic multiple sclerosis. For instance, discussing the sensitivity of tests like the MOG antibody test or cell-based assays, and highlighting how these tests can distinguish MS from conditions like neuromyelitis optica. It’s crucial to emphasize that proper testing, in both serum and cerebrospinal fluid, is vital to prevent misdiagnosis. For example, MS-defining lesions can appear in other diseases, which is why the incorporation of the central vein sign into the new diagnostic criteria is so important. The central vein sign helps us pause and ask: Is this definitively MS? So, while the new criteria are incredibly helpful, they are also protective, especially through the incorporation of optic neuritis and the central vein sign.
Neena Cherayil, MD: For neurology providers—who are often the first to encounter patients with optic neuritis—it’s critical to get this information to them. This includes optometrists and ophthalmologists, since patients often present with eye pain before recognizing vision loss or noticing a smudge in their vision. Many times, these patients come to me with significant vision loss despite having a normal fundus exam. Over two-thirds of optic neuritis cases in MS are retrobulbar, meaning there may be no optic nerve swelling and the fundus exam could appear normal, even though the afferent exam wouldn’t be. Educating providers to recognize that optic neuritis can present in this way is essential, along with emphasizing the need for prompt initiation of steroids, which can significantly reduce visual and other morbidities. As Elena mentioned, differentiating between MS, MOGAD, and other mimickers is also crucial for ensuring the best visual outcomes. Ongoing studies are exploring whether earlier and more aggressive treatment with IV steroids or plasmapheresis for undifferentiated optic neuritis—where it’s unclear if it’s MS, NMO, or something else—can preserve vision. These are areas we need to keep an eye on for the future.
