Review Question - QID 105383

The patient presents with optic neuritis secondary to multiple sclerosis. Another ophthalmic condition that may be found in multiple sclerosis is internuclear ophthalmoplegia.

In optic neuritis, patients present with painful, monocular vision loss that usually evolves over hours to days. One third of patients may have papillitis on exam. In the remainder of patients, the inflammation is retrobulbar and may not be seen on physical examination. Chronic signs of optic neuritis are a relative afferent pupillary defect, color desaturation, and optic atrophy. Internuclear ophthalmoplegia is more common in patients with MS. In this syndrome, an adduction deficit of the ipsilateral eye is present and there is horizontal gaze nystagmus in the contralateral abducting eye. The lesion involves the medial longitudinal fasciculus (MLF).

The optic neuritis study group discusses the clinical profile of optic neuritis. 77.2% of the patients were women. Mean age was 31.8 years. Pain accompanied the visual loss in 92.2% of cases. The optic disc appeared swollen in 35.3% of the patients and normal in 64.7%.

Patel and Lundy discuss the ocular manifestations of autoimmune diseases. Rheumatoid arthritis, juvenile rheumatoid arthritis, Sjögren's syndrome, the seronegative spondyloarthropathies, systemic lupus erythematosus, multiple sclerosis, giant cell arteritis, and Graves' disease are autoimmune disorders commonly encountered by family physicians. These autoimmune disorders can have devastating systemic and ocular effects. The most commonly encountered ocular manifestation is uveitis, inflammation of the iris, ciliary body, or choroid.

Figure A is a classic depiction of papillitis. Note the lack of sharp borders of the optic disk (which is seen in normal nerves). Note that papillitis may not be present on exam if the inflammation is retrobulbar. Illustration A shows hyperintensity of the optic nerve on MRI, indicative of optic neuritis. Illustration B shows multiple plaques seen on MRI in a patient with relapsing and remitting MS.

Incorrect Answers:
Answer 1: Cataracts are associated with chronic steroid use and radiation, but are not more common in patients with multiple sclerosis.
Answer 2: Age-related macular degeneration is not associated with multiple sclerosis.
Answer 3: Glaucoma is not associated with multiple sclerosis, but is more common in African American patients.
Answer 4: Uveitis is associated with many rheumatologic conditions, but not with multiple sclerosis.