Role of Neuro-Ophthalmologists in Care Paradigm of Multiple Sclerosis

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EP: 1.Role of Neuro-Ophthalmologists in Care Paradigm of Multiple Sclerosis

EP: 2.Impact of Optic Nerve Inclusion on Early MS Diagnosis and Treatment

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 1, Grebenciucova, an assistant professor of neurology, and Cherayil, an assistant professor of neurology and ophthalmology, provide context on the job of neuro-ophthalmologists in the multidisciplinary care of MS, especially when it comes to managing optic neuritis. The duo discuss the specialized tools and expertise neuro-ophthalmologists bring to diagnosing and understanding visual symptoms, and how their insights help differentiate MS from other conditions with similar presentations. Overall, the conversation emphasized the importance of a collaborative approach in providing comprehensive care for patients with MS-related visual challenges.

Transcript edited below for clarity.

Marco Meglio: How important are neuro-ophthalmologists in the interdisciplinary and multidisciplinary care of MS? What unique expertise do you bring to the table, and how important is it to have neuro-ophthalmologists in the multidisciplinary care of MS?

Elena Grebenciucova, MD: That's a wonderful question. As a neuroimmunologist, we are not trained in neuro-ophthalmology, so when we see patients with optic neuritis, we generally want to understand a little more about how their optic nerve is involved. Is it what we call perineuritis? Is it optic neuritis? Obviously, MRIs are helpful and can help answer some of those questions. But the role of neuro-ophthalmologists is really critical, because they can perform optical coherence tomography (OCT) and provide more information on the damage we are seeing, as well as look into other issues that might be missed during a non-dilated exam in the neurology office. So we generally always refer patients with optic neuritis or suspected optic neuritis to our neuro-ophthalmology colleagues, and they often change the way we think about what happened to the patient.

There are classic optic neuritis cases, but there are also some very confusing ones where it's unclear whether the optic neuritis we see is truly inflammatory or ischemic in nature. They can also be very helpful in differentiating optic neuritis from conditions like long add, multiple sclerosis, or neuromyelitis optica. So, neuro-ophthalmologists are absolutely essential in the care of people who are presenting with visual symptoms.

Neena Cherayil, MD: As a neuro-ophthalmologist, I'll heartily echo that. I agree—we have the tools and exam skills to examine the visual system of the brain. This involves direct examination of both the front and back parts of the eye, and many autoimmune conditions can have comorbid conditions in the anterior segment of the eye. For example, uveitis is quite common in sarcoidosis and can be a mimic of MS, so it's important to consider it in the differential diagnosis of optic neuropathies. The additional testing, which includes parametric visual field testing, OCT, and management of the optic nerve and retina on a microscopic level, is also crucial in evaluating MS, and these are uniquely in the wheelhouse of neuro-ophthalmologists.