Here is My Question:
My daughter is newly diagnosed. Her only symptom was eye sight. Since her brain MRI showed many lesions (some large) one doctor said she should take Tysabri or Copaxone with steroids. A second opinion said Tysabri and no to Copaxone. She is JC negative. I have been reading about rebound coming off Tysabri so that scares me. Her spinal MRI was clear but had bands in CSF. How do we make this decision for the long term outlook? Right now she has no symptoms so this is hard to understand. Tysabri is a very safe medication to be on if you are JC antibody negative and remain JC antibody negative while on therapy.

Answer:
The risk of rebound is only a problem if you are not switched to another medication in a timely fashion after discontinuing the Tysabri.

Most rebound symptoms occur around 3 months after the last infusion. Hopefully your daughter will not have a need to discontinue the Tysabri.  However, if she does need to stop it, there are many treatment options that can be started within 1 month of discontinuing the Tysabri to avoid the risk of rebound.
 
Benjamin Osborne, MD
Associate Professor of Neurology and Ophthalmology
Director, Neuromyelitis Optica (NMO) Clinic
Director, Neuro-Ophthalmology Clinic
Associate Director of the NIH/Georgetown Neurology Residency Program
Medstar Georgetown University Hospital
3800 Reservoir Road, NW 7PHC
Washington, DC 20007

Here is My Question:
How many OCTs are necessary and over what stretch of time to rule demyelination in or out? I had an OCT 18 months ago which showed damage. I had another recently and when I asked about it my eye doctor just said really we can only get a picture of this over time and said he could not compare the new one to the one from 18 months ago because it did not make sense to do so. However my neurologist is interested in a repeat OCT. I am confused.

Here is my answer:
 
The question of when and how often to perform OCT depends on why the test is being ordered.
 
If you have a clear cut definite diagnosis of multiple sclerosis, there is not great evidence that you need to have annual repeat OCT scans.  However your neurologist may want to track the retinal nerve fiber thickness as a way of monitoring your MS.
 
I usually get repeat OCT scans in my patients who have either atypical cases of optic neuritis, a questionable diagnosis of multiple sclerosis or unexplained vision loss.
 
Some patients on an MS medication called Gilenya (fingolimod) have annual OCT scans of the macula to help monitor for a rare side effect (macular edema).
 
Sincerely,
 
Benjamin Osborne, MD
Associate Professor of Neurology and Ophthalmology
Director, Neuromyelitis Optica (NMO) Clinic
Director, Neuro-Ophthalmology Clinic
Associate Director of the NIH/Georgetown Neurology Residency Program
Medstar Georgetown University Hospital
3800 Reservoir Road, NW 7PHC
Washington, DC 20007

Question:
If I have anterior ischemic optic neuropathy does that mean I have multiple sclerosis?

Answer:
Anterior ischemic optic neuropathy is not associated with multiple sclerosis.

There are two forms of anterior ischemic optic neuropathy, non-arteritic and arteritic.
The arteritic form is usually seen in people above the age of 50 years old and is associated with giant cell arteritis (also known as temporal arteritis).
​
The non-arteritic form is usually seen in people above the age of 40 years old and may be associated with obstructive sleep apnea, hypertension (high blood pressure) or diabetes mellitus.

Benjamin Osborne, MD
Associate Professor of Neurology and Ophthalmology
Director, Neuromyelitis Optica (NMO) Clinic
Director, Neuro-Ophthalmology Clinic
Associate Director of the NIH/Georgetown Neurology Residency Program
Medstar Georgetown University Hospital
3800 Reservoir Road, NW 7PHC
Washington, DC 20007

Question:

​Four days ago I noticed that my distance vision was much worse than usual. While driving to an appointment I noticed that I could not read road signs until I was right under them. Three days before that I had no problem. (I did not go anywhere the other 2 days but did not notice a problem around the house.)

In February 2016 at my annual ophthalmologist exam my corrected vision was 20/20 near and far.

I have never had this problem before but I had become moderately over-heated that day so I went home and rested with the A/C on. But my vision did not improve. I could not read the banners on the TV at all either.

So yesterday I went to the emergency room (holiday weekend, my neuro unavailable) where a neurology PGY3 did a very thorough exam and found nothing abnormal except my usual mild hyper-reflexia and poor distance vision of 20/200 in BOTH eyes with my glasses on. My near vision was still 20/20 with my glasses.

An ophthalmology resident (? PGY3) also saw me and did a detailed exam including a dilated fundoscopic exam. She saw no abnormalities except for the poor distance vision. I saw colors fine and had grossly normal visual fields.

Neurology says it is not from MS or otherwise neurologic and ophthalmology said I should see my eye doctor to get new glasses. They admitted they don't really know what is wrong or why this happened.

I know it is not like optic neuritis which I may have had 6-7 months ago for the first time, though I doubt it. (At that time I had 3 days of right eye pain with eye movement and no other symptoms or findings on exam by my own ophthalmologist but doc said mild ON. It went away without treatment.)

But how can you have a refractive change from 20/20 to 20/200 over a period of hours?

I feel fine otherwise except that I am getting a headache from squinting.

I hope I can see my own ophthalmologist in the next couple of days and that new glasses will help because I am homebound until I can see better.

Should I have an MRI? It has only been a year since my last one but I had no vision problems then.

I am so happy that my near vision has been spared because I don't know what I would do with myself if I could not read and knit. But I worry that it might become affected too.

I am 59 yo and have had MS since 2003.

Answer:
Your change in your distance vision that is correctable with prescription eyeglasses is called myopic shift (you have become more near sighted).

This is not a manifestation of multiple sclerosis or optic neuritis.

One of the most common causes of myopic shift is cataracts (some patients with MS may develop cataracts if they have had frequent doses of steroids over the years for treatment of MS relapses)
Other causes of myopic shift may include medication side effects (for example topirimate (also known as Topamax) may cause myopic shift).

I recommend you follow up with your ophthalmologist to review if you have any medications or cataracts that could be causing this change in your vision.

Benjamin Osborne, MD
Associate Professor
Departments of Neurology and Ophthalmology
Georgetown University Hospital

Here is My Question:
I am a 43 year-old female and was recently diagnosed with MS just last month. Late December 2015, I suffered from an attack of optic neuritis and spent three days in the hospital for IV steroid treatment and other diagnostic tests. Other than the IV steroids and a three week taper of oral prednisone, I have never been on any other DMTs or immunosuppresants. The ON has been my only symptom, as well as some minor facial tingling. My MRIs showed approximately 3-4 active lesions and 3-4 inactive lesions. None on C or T spine. I take medication for hypertension and hypothyroidism.

My MS specialist neurologist is recommending Rutixan as my first form of treatment for MS. I am JC positive, not sure of exact level. I know there have been no reported cases of PML in MS patients treated with Rituxan, and that the risk is about 1 in 25,000. Is Rituxan normally used as a front line treatment for MS? It seems very aggressive to me, but my neuro said that he wants to treat it aggressively, as I am so young and have so little disability at this point. He wants to keep it that way. Do the benefits of this treatment outweigh the risks of PML?

​How long could I safely take Rituxan before having to consider switching to another DMT? I've read that patients can only take Rituxan for 2 years max.? I have ruled out Tysabri, Tecfidera, and Gilenya due to PML risk. How small or large is the PML risk in Gilenya as compared to Rituxan? Is Aubagio more effective than the interferon drugs in regards to delaying disease progression, number of relapses, and number of MRI lesions? Not looking for recommendations, just a little guidance. =) 

Answer:
Being JC Ab positive has only been shown to a significant predictor of risk for PML in patients taking natalizumab (Tysabri) and it has not been shown to be a valid predictor of PML in patients on other MS therapies.

Because there are only a handful of cases of PML in patients taking Gilenya (five patients) or Tecfidera (three patients), there are no recommendations for screening patients with the JC Ab test to guide therapy choices. 

No one knows the actual risk of PML with the oral medications but it appears to be significantly lower when compared to natalizumab.  While Aubagio has not had any reported cases of PML yet, I would not be surprised if a case or two is eventually reported over the next several years.

As you mentioned, the risk of PML with rituximab is also very low.  Rituximab is sometimes used as an option for treating relapsing MS patients but it is not commonly used as the first medication.
You will need to discuss with your neurologist how much “risk” you are willing to take in being aggressive in the treatment of your MS for the future potential benefits (decreased disability, decreased relapses, decreased MRI lesions).  Once you decide how much risk you are willing to take you will be better prepared to choose which medication to start. 

Please type in "PML" or "JC" in the search box in the upper right hand corner of this page and you will find many questions and answers about these topics.

Benjamin J. Osborne, MD
Department of Neurology
MedStar Georgetown University Hospital

PLEASE NOTE:  The information/opinions on this site should be used as an information resource only.  This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.

Here is My Question:
My husband was recently diagnosed with Remitting Relapsing MS in September. He has been on Glatopa for a little over 2 months. Recently, for about a month and half his fatigue has increased significantly. His doctor put him on Amantadine, he was taking one at 12pm at first and then tried one in the morning and one around 12. He was still falling asleep and felt tired but had insomnia at night. Of course he was napping for about 2 hrs when he got home from work at around 5pm.

He was recently put on Ritalin 20 mg. He took one yesterday and said he blackout out for a moment. His vision went out. Is that a common side effect. It really frightened me. He said he was reading symptoms and is wondering if maybe he imagined it? Is this a good drug to take? Is 20 mg ok or would a lower dosage be better? Is there anything else he can do that will help? He is slightly overweight and also does not exercise. He has improved his eating habits but they are not ideal. Thank you for your help.

Answer:
Transient loss of vision is not a common side effect of Ritalin. I recommend you and your husband discuss this episode of “blackout” with the physician who prescribed it to make sure it is the appropriate medication for him. 

Dr Osborne

Here is My Question:
Thank you, Healthcare Journey Doctors, for all the help you are giving. You are providing a great resource for which many are grateful.

I'd like to ask about hyperintensities in a patient over 40 with a history of optic neuritis: a) if optic neuritis occurs with nonspecific hyperintensities, is the risk of MS raised and by how much? Or is this just if the hyperintensities occur in MS specific areas?; b) in such a situation is a mild increase in nonspecific hyperintensities between mris in any way significant?; c) how likely is it the optic neuritis and nonspecific hyperintensities would have different pathologies?; d) how would you recommend treating such a patient? Is treatment by a neurologist advised? What about symptom treatment? Is it recommended to treat nonspecific symptoms of MS (eg fatigue) with meds in such a patient or should the patient look for answers elsewhere?

Answer:
These are excellent but complicated questions about optic neuritis and an abnormal MRI brain with white matter hyperintensities.
​
In general, having one WM lesion that looks like a demyelinating lesion (based on shape, size and location) increases the risk of developing MS over the next 5 years to about 75-80%
Having no WM lesions in the setting of optic neuritis is associated with a lower (25%) risk of developing MS in the next 5 years.

Most MS specialists recommend treating patients with WM lesions and a history of optic neuritis with one of the approved immunomodulatory drugs for MS (for example, an interferon, glaitramer acetate, or one of the oral medication for MS).

In patients with no WM lesions, most neurologists would not recommend treatment.
Regarding "non specific" WM lesions, the significance of these findings are not clear in patients without a diagnosis of MS yet.  One has to take in to consideration other diseases that might cause non specific WM lesions, such as diabetes mellitus, hypertension, heart disease, migraine headaches, prior traumatic brain injury, etc.  
​
I would not recommend treatment of non-specific symptoms such as fatigue without first seeing a general physician (primary care doctor) to rule out other potential causes of "fatigue" (such as hypothyroidism, vitamin B12 deficiency, etc.).

Benjamin Osborne, MD
Associate Professor
Departments of Neurology and Ophthalmology
Georgetown University Hospital

Here is My Question:
How does someone know whether or not their eye pain is related to Optic Neuritis?
​
Answer:
Typically eye pain due to optic neuritis is described as a soreness/pain behind the eye that is worse with eye movement.  Sometimes the pain may preceed the vision loss associated with optic neuritis by a couple of days.

However, the only way to know for sure is to have a eye exam by an ophthalmologist.

Benjamin Osborne, MD
Associate Professor
Departments of Neurology and Ophthalmology
Georgetown University Hospital

Question:
I was diagnosed with RRMS 10 years ago. My first flare was 12 years ago. All previous flares and symptoms (except fatigue) seemed myelopathic. I have been on Avonex (18 mos), Tysabri (6yrs), and Tecfidera (2yrs). A year ago I stopped taking DMTs mostly due to apathy but my neuro OK'd this because MRI has been stable except for evolution of small lesions into small black holes.

Recently I developed right eye pain which was increased with eye movement. Pain is not severe but dull ache "behind" the eye. Right upper quadrant is a little blurry but no noticeable vision change otherwise. My ophthalmologist says it is mild optic neuritis and that no treatment is needed. This is fine with me since steroids do NOT agree with me. My questions are first, is it not unusual to develop my first episode of optic neuritis at this point? And second, should I go back on Tecfidera? 

Answer:
Since you are not currently on treatment, it is not unusual to have a relapse 12 years into your course of MS.  While optic neuritis is a common first attack in multiple sclerosis, it can occur at any time during the relapse remitting phase of the disease.

Over time, about 75% of patients with MS will have some type of visual problem (optic neuritis, double vision, nystagmus, etc.).

As to whether you should go back on Tecfidera, that is something you need to discuss with your neurologist.  I would recommend you start treatment with some immunomodulatry therapy as you are still having relapses; whether it should be Tecfidera or another medication is something you and your neurologist can discuss.

Benjamin Osborne, MD
Associate Professor
Departments of Neurology and Ophthalmology
Georgetown University Hospital

Here is My Question:
Is it possible to have multiple sclerosis without any vision involvement? The patient had demyelinating plaques in the MRI with typical clinical findings of ataxia, hyperreflexia and clonus. He never complained of visual symptoms. The optic nerve was normal. 

Second question: Do we treat patients with prophylaxis such as pegylated interferon if they present with a first attack with no such attacks before?
Thank you.

Answers:

1. Yes it is possible to have multiple sclerosis without any vision involvement.  The majority of patients with multiple sclerosis will eventually have problems with their vision due to the MS but a small minority may never have vision problems due to the MS.

2. In general most multiple sclerosis specialists do recommend treating patients who have had a first attack of demyelination suggestive of MS, even if they do not meet the diagnostic criteria for MS yet.  There have been several trials involving almost all of the injectable medications (interferons and glatiramer acetrate) demonstrating benefit from early treatment after the initial first attack.

Dr Osborne

Benjamin J. Osborne, MD, is an attending physician in the Department of Neurology and an associate professor of neurology and ophthalmology at MedStar Georgetown University Hospital.Dr. Osborne is board certified in neurology, with concentrations in neuro-opthalmology and multiple sclerosis.

Here is My Question:
I have MS and went blind in one eye for two days. Scariest thing ever. My doctor said this is common in MS. My questions are why is this common in MS? Why does this happen/what is going on in my body with the MS that would cause just one eye to loose sight (so weird), and is there anything I can do to prevent it from happening again??

Answer:
Losing vision in one eye can happen in MS due to a condition called optic neuritis.  The vision becomes blurry because of inflammation in the optic nerve (the optic nerve connects your eye to your brain).  With MS, the body's immune system can sometimes cause inappropriate inflammation and damage to the optic nerve leading to temporary vision loss. The immune system's attack on the optic nerve may flare up, and then the vision becomes blurry.  The vision returns back to normal (or almost back to normal)  when the inflammation resolves and the optic nerve has time to heal.  

Usually patients do not go completely blind but experience hazy or decreased vision associated with pain in the eye. 

The eye pain is typically worse with eye movements.  Usually the vision loss associated with optic neuritis will resolve after a few weeks but can improve more rapidly if treated with intravenous steroids.  

To prevent recurrent episodes of optic neuritis, patients with MS should be on some form of immunomodulatory therapy that is FDA approved for relapsing multiple sclerosis (for example, interferon therapy, glatiramer acetate, natalizumab, or one of the several pills now approved for MS). To figure out which medicaiton is best for you, consultation with your neurologist or an MS specialist is required.

Finally, not all forms of transient vision loss are due to multiple sclerosis.  If you or your neurologist are not sure what caused your vision loss, consider seeing a neuro-ophthalmologist for further evaluation."

Sincerely,

Benjamin Osborne, MD
Associate Professor
Departments of Neurology and Ophthalmology
Georgetown University Hospital

Here is My Question:
Why does my vision get blurry when I get hot? It happens a lot in the summer and it is so annoying! Is there anything I can do about it?

Answer:
Blurry vision is a very common symptom in patients with multiple sclerosis.  Blurry vision that is triggered by heat typically occurs in the eyes of patients who have had a prior episode of optic neuritis.  This phenomenon was first described an ophthalmologist in the 19th century and is called Uhtoff's phenomenon, in his honor.

Typically patients who have had optic neuritis will have very good recovery of visual acuity in the affected eye.  However, if the body gets overheated (for example after vigorous exercise or in the summer heat) the vision in the previously affected eye will temporarily get blurry.  Once the body cools off (air conditioning, or drinking an ice cold beverage) the blurry vision resolves rapidly.

Uhtoff's phenomenon is not  considered an MS relapse but is a reminder that the optic nerve has suffered prior injury from the multiple sclerosis.  If both eyes have had optic neuritis in the past then both eyes may become blurry in the heat. 

The best way to prevent Uhtoff's phenomenon is to stay cool and well hydrated. Some patients with MS are so sensitive to the heat that they wear ice pack vests (these are vests with pockets which can be stuffed with ice packs) when going outdoors in the summer.  

If you do notice that your vision becomes blurry but does not return back to normal after your body has cooled off, you should consider contacting your neurologist or ophthalmologist (in particular if the blurry vision lasts > 24 hours).

Sincerely,

Benjamin Osborne, MD
Associate Professor
Departments of Neurology and Ophthalmology
Georgetown University Hospital

#blurryvision #Uhtoffs #multiplesclerosis