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Vision Problems and MS
Dr. Jacqueline Nicholas, a neuroimmunologist and MS specialist at the OhioHealth Multiple Sclerosis Clinic, talks about vision problems and MS.
00:00:00:00 - 00:00:33:06
Dr. Jacqueline Nicholas
There are lots of different causes of optic neuritis, but in the setting of multiple sclerosis, it’s caused by an immune attack of someone’s own white blood cells attacking the myelin coating on the optic nerve. And when that happens, people will experience oftentimes blurred vision in one or both eyes, and then they can have pain with eye movements.
00:00:33:08 - 00:00:58:14
Dr. Jacqueline Nicholas
And sometimes it just, you know, feels like there’s a missing spot in the center of your vision or a blurring or, you know, could go completely out. In terms of treatments, the good news is that there are lots of options. When we identify that somebody has an acute optic neuritis, meaning that it’s fairly new and that there’s inflammation, typically what we use is steroids,
00:00:58:14 - 00:01:26:00
Dr. Jacqueline Nicholas
and most classically that would be intravenous steroids, so where you get an IV placed and receive something called methylprednisolone, or Solu-Medrol, and that’s usually a gram of that once a day for anywhere between three to five days. And most people notice, within a couple of days of that, that they would have some improvement and then could continue to have improvement for, you know, weeks to months after that.
00:01:26:02 - 00:01:51:23
Dr. Jacqueline Nicholas
Typically, we see optic neuritis really in the form of a relapse. So we, you know, when we use the term “progression,” we usually think of something that is slowly worsening over a very long period of time. And so typically, in MS, this would be something that somebody would notice these symptoms more of what we'd say subacutely, over maybe hours to days where they notice that there’s something off with their vision.
00:01:51:23 - 00:02:19:15
Dr. Jacqueline Nicholas
And then over a period of a couple of days, maybe even a week or so, they could feel like it gets worse and worse. But then there’s a point at which even without treating somebody with steroids, you know, somebody could then start to improve if they didn’t seek medical attention. It just typically, if we give steroids or for apheresis treatment in the setting of MS-associated optic neuritis, it accelerates the recovery.
00:02:19:15 - 00:02:40:08
Dr. Jacqueline Nicholas
But I’ll say in terms of progression, you know, it’s interesting. I do see people who have primary progressive MS, where we know that their symptoms have been gradual since onset. And when I do some of my tests, looking in their eyes or shining a flashlight in their pupils, I can see signs that they’ve had an optic neuritis in the past.
00:02:40:08 - 00:02:55:14
Dr. Jacqueline Nicholas
But that individual never had the symptoms noticed acutely, but it’s more of something that may have come on gradually or was so subtle they didn’t notice.
Vision problems are often among the first symptoms that appear in people with multiple sclerosis (MS). Since they’re easy to notice and affect day-to-day life, visual symptoms might prompt someone to see a healthcare professional to find out what’s causing them.
“The symptom that made me pay enough attention to go to the doctor was my vision change,” one MyMSTeam member wrote. Visual problems can also happen later in the course of MS.
Seeking help for vision problems is important because they can affect your balance and put your safety at risk. Vision issues can also affect your independence, your ability to work, and your ability to travel.
As with other symptoms of MS, everyone experiences vision problems a little differently. Here’s how members of MyMSTeam have described vision and eye problems:
MS can affect vision in several ways. Vision problems associated with MS may include diplopia (double vision), nystagmus (uncontrolled eye movements), eye floaters, and optic neuritis.
Diplopia can be an early symptom of MS. In people with MS, diplopia is related to damage to the nerves that control eye movement. This causes the eyes to become misaligned.
Double vision is sometimes temporary but can be lasting.
Nystagmus is a vision problem that causes the eyes to move from side to side or up and down in a repetitive, uncontrolled manner. It’s sometimes called “dancing eyes.” Nystagmus can also prevent a person from holding a steady gaze. This can lead to or worsen dizziness and nausea, which can contribute to balance issues and falls. Nystagmus may last, or it may come and go.
MS can damage the nerves in the cerebellum or brainstem of the central nervous system and cause nystagmus. The cerebellum and brainstem are both areas of the brain responsible for muscle movement, vision, and balance. Nystagmus can also happen if the optic nerve is damaged, which can make it harder for the brain to process what you see.
Floaters are common and can happen with or without MS. These spots in your vision often move or shift when you try to look directly at them. You may have one or many. Floaters often appear as small dots but can also show up as rings, lines, or other shapes.
Floaters have many causes, including normal aging and uveitis (inflammation of a layer lining the wall of the eye). Floaters are usually harmless, but sudden new floaters should be checked by a doctor.
Optic neuritis is among the common eye problems caused by MS, and it’s often one of the first symptoms of the condition. “People experience blurred vision in one or both eyes and often also experience pain with eye movements,” explained Dr. Jacqueline Nicholas, a neurologist and MS specialist at the OhioHealth Multiple Sclerosis Clinic in Columbus, Ohio.
MS can also cause a scotoma — a blurry, dim, or blind spot. A scotoma may occur in the center of the visual field without changing peripheral vision. Optic neuritis may also affect color vision and make colors appear gray.
Optic neuritis can happen in MS, but it can also happen in neuromyelitis optica, a rare condition that needs different treatment. Because the treatments used to prevent future attacks are different, it’s important to get the right diagnosis.
Optic neuritis in MS is commonly due to optic nerve inflammation and demyelination. “It’s caused by the immune system attacking the myelin coating on the optic nerve,” Dr. Nicholas said.
Vision loss is the first MS symptom for 1 in 4 people with MS, according to Multiple Sclerosis Trust. As many as 7 out of 10 people with MS will experience optic neuritis at some point, according to the nonprofit.
Optic neuritis doesn’t affect only people with MS. Between 1 and 5 people in 1,000 in the general population experience optic neuritis, per the Multiple Sclerosis Trust. The MS Trust also notes that much like MS, optic neuritis tends to affect more women than men and develops between the ages of 20 and 40.
This vision problem can occur regardless of a person’s type of MS. “We see optic neuritis in relapsing MS because it typically comes on in the form of a relapse,” Dr. Nicholas said. People who have secondary progressive MS can also develop optic neuritis.
“For many people with optic neuritis, it often improves with time, although improvement may not be complete,” Dr. Nicholas explained. “The good news is that there are options to help individuals with decreased vision, often offered through low-vision clinics.” Treatment options for vision problems may include steroids during onset, plasmapheresis, and specialized lenses.
High doses of corticosteroids (steroids), such as methylprednisolone (Solu-Medrol), are often the go-to treatment for an episode of optic neuritis in people with MS. Steroids are commonly delivered intravenously (through a vein). Dr. Nicholas said the dosage is “usually a gram of that once a day for anywhere between three to five days.” High-dose oral steroids can also be used to treat optic neuritis, but only after initial treatment with intravenous forms.
Floaters are usually considered harmless and typically aren’t treated by doctors. In extreme cases that significantly affect vision, some doctors will recommend surgery to try to remove floaters. To help relieve problems from floaters, wear sunglasses outside and use protective eyewear in bright light.
Nystagmus is more complicated than other MS-related vision problems. There are fewer treatment options to address involuntary eye movements. Sometimes, eyeglasses or contact lenses help slow the uncontrolled movements of the eyes and improve vision. Drugs like gabapentin (Neurontin) may be used to reduce eye movement or twitching and spasms.
In rare instances, surgery is used to address nystagmus. However, surgery doesn’t directly address the symptoms of nystagmus.
Double vision that occurs due to an MS relapse often resolves itself partially or fully. Treatment with steroids can hasten recovery. Some people wear a patch over one eye to help with diplopia.
A Fresnel prism is a special lens that attaches to glasses and adjusts the way light enters a person's eyes. In some instances, a Fresnel prism can help realign the two images in double vision by altering the way visual information enters the eye.
Double vision sometimes persists for a long time. In these cases, Botulinum toxin or surgery may be used to help bring the eyes back into proper alignment.
On MyMSTeam, people share their experiences with multiple sclerosis, get advice, and find support from others who understand.
Have you experienced vision problems related to MS? Do you get eye floaters or double vision? Let others know in the comments below.
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