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Home , Blurred vision, Diplopia, Optic neuritis, Oscillopsia

Vision Problems IN

LIZ DIAGNOSED IN 2002

A vision problem is the first symptom of adapt. Some have even turned vision MS for many people. The sudden onset of problems into advantages. Flo Fox, a double vision, eye or blurring can be photographer living with MS in New York terrifying, and the knowledge that vision City, says that her adaptations helped her may be compromised makes people with to become a better photographer, and MS anxious about the future. Fortunately, she has taught other people with vision the prognosis is good for recovery from problems how to use various types of many vision problems associated with MS. cameras adjusted to their abilities. Blindness can occur, but is very rare. This document discusses the main MS- More people are faced with the need related eye problems, but people with MS to accommodate to persistent vision may have other eye problems, just like changes. If vision problems do persist, anyone else. Regular eye care and periodic resulting in permanent low vision, there examinations are important for everyone. are resources and tools to help people

Vision Problems | 1 people recover within a month, others MS-Related Vision need up to a year. Most people regain Problems normal or close-to-normal sight. However, the quality of their vision, including Optic , an of color or depth and contrast the optic , is the most common sensitivity, may be reduced after an episode visual disorder associated with MS. of . Symptoms of optic neuritis include , dimming of colors, pain Temporary worsening of vision may also when the eye is moved, blind spots occur after recovery from optic neuritis. and lessening of ability to see contrast Hot showers or baths, exercise, a bout (contrast sensitivity). Double vision of flu, or a fever may all trigger dimmed () and involuntary movement of color, blurred vision, and other problems. the eyes () are other common Nerve fibers that are demyelinated problems, both linked to inflammation of (have lost their insulation) or are brain stem areas that control movements remyelinating (under repair) are very of the eye. Diplopia disturbs vision sensitive to higher temperatures. These by producing double images. Because heat- related symptoms resolve when the seeing double can affect a person’s person cools off, be it from ice packs, over- of orientation in space, diplopia the-counter fever reducers, cool drinks, may interfere with balance. Nystagmus air conditioning or a soak in a cool tub reduces vision in a number of ways, of water. “The symptoms mean the optic including : an experience of nerve is not conducting information as the world “wiggling.” The wiggling may well as it should,” said Dr. Gregory P. be horizontal or vertical, and may occur Van Stavern, a neuroophthalmologist in one eye, or both. It typically causes at Washington University in St. Louis. impaired vision and, often, loss of balance. “This doesn’t mean a person is having a These three disorders are not linked to new attack of MS. If symptoms persist each other and usually occur separately. for more than a day or so after the body temperature has returned to normal, then Optic Neuritis contact a physician.” Treatment Optic neuritis is a type of MS relapse that affects one or both optic . The In the Optic Neuritis Treatment Trial symptoms of eye pain and blurred vision (ONTT), high-dose intravenous steroids may worsen over the first few days to two were shown to accelerate recovery weeks, and then gradually improve. Some from visual symptoms and to delay

Vision Problems | 2 development of MS. Dr. Roy W. Beck, of Texas, Southwestern Medical Center executive director of the Jaeb Center in Dallas, recommends IVIG for people for Health Research in Tampa, Florida, with MS who have , are manic- who was principal investigator, said depressive, or cannot tolerate steroids for “Intravenous at the time other reasons. of a first episode of acute optic neuritis There is little information on the appear to have a short-term beneficial effectiveness of complementary therapies effect… delaying the time to the for vision problems, but some people development of a second demyelinating report relief from vitamin B-12 shots event, and therefore a diagnosis of during an optic neuritis episode. “We definite MS. However, there did not know function depends appear to be a long-term benefit from a on vitamin B-12 and folate,” said Dr. single course of IV steroid treatment.” Thomas R. Hedges, III, professor of The ONTT also found that people and at Tufts treated with oral steroids did not do University School of Medicine and as well as those that had intravenous the director of neuroophthalmology at treatment or were not treated at all. the New England Medical Center. “I Oral steroids apparently increased encourage people to take multivitamins.” the risk of recurrence. According to Dr. Frohman, anyone If the initial symptoms of optic neuritis coming in for a vision problem should are mild, a doctor may decide to allow be screened for vitamin B-12 levels, as a the disorder to resolve on its own. And deficiency can mimic symptoms of MS. the same is true for subsequent episodes Some people with progressive forms of optic neuritis; mild symptoms can be of MS develop persistent optic nerve left untreated while symptoms that are problems, even without having had severe enough to interfere with everyday attacks of optic neuritis. Over the years, activities are generally treated with high- vision may worsen in these individuals, in dose steroids. spite of MS treatment. Intravenous immunoglobulin (IVIG) may be an option for people who are Low-Vision Specialists unable to take steroid medications. While the prospect for recovery from Although a study at the Mayo Clinic had optic neuritis is generally good, there inconclusive results as to the efficacy of are times when vision problems persist. IVIG as a treatment, Dr. Elliot Frohman, Poor vision caused by optic neuritis associate professor of neurology and cannot be helped with eye glasses director of the MS Program at University because the problems are caused by poor

Vision Problems | 3 nerve conduction. If problematic vision loss continues, a low-vision specialist Diplopia (Double can analyze your visual function and Vision) and Nystagmus recommend aids and strategies to help you make the most of the vision you have. Double vision may lead to impaired depth Low-vision specialists are licensed doctors perception, imbalance, and difficulty of ophthalmology or . The reading, walking and driving. If double specialist will assess how your eyesight vision occurs as part of an MS relapse, functions in day-to-day living — not just it is likely to resolve spontaneously and how well you do on an eye chart exam. completely. Some people are left with He or she may ask questions about glare, longstanding, permanent double vision contrast, sensitivity to light, and color after incomplete recovery from a relapse. perception. In addition, special charts Progressive MS may also cause persistent may be used to measure other aspects of double vision. your vision. A typical session with a low- When people have nystagmus, they may vision specialist lasts two to three times feel dizzy and unsteady. They may feel longer than a standard eye exam. that the world is moving (oscillopsia) or The low-vision specialist will want as that they are moving abnormally (). much information as possible — not Nystagmus may occur as a relapse only about your medical and vision symptom or as a chronic symptom of MS history, but your individual needs. If you if recovery from a relapse is incomplete. have an occupational need, a hobby or a It may be a part of progressive MS favorite activity, explain it during your particularly in individuals examination. Your low-vision specialist with poor vision. may be able to prescribe or recommend an optical device, such as microscopic or Treatment telescopic eyewear, a magnifier, a filter Anyone with double vision or nystagmus or a closed circuit television (CCTV) must be evaluated by an ophthalmologist, system, that fits your specific needs. neurologist, or neuro-ophthalmologist, to determine the cause of the double vision. If the double vision or nystagmusare due to a relapse of MS, the relapse may be treated with steroids in order to shorten its duration.

Vision Problems | 4 Persistent diplopia may be treated with spectacles with temporary press-on Living with Low Vision (Fresnel) prisms. If the temporary prism If your vision has become permanently is effective for an extended period of impaired, changes in your home and work time, the prism can then be ground in to place can make you more comfortable a new pair of spectacles. and productive. “If there’s misdirection, sometimes we can ∫∫ Organize your possessions so that they are adjust the muscles surgically to realign easier to find. the eyes. If all else fails, patching — or ∫∫ Increase your lighting levels, and make sure just applying frosted tape to the inside that important areas, such as your desk, of one eyeglass can reduce double dressing area, and stove, are well lit. The vision,” Dr. Hedges said. He emphasizes type of lighting can also make a difference that people with double vision don’t need — experiment to find out what works best for you. to alternate the patch from eye to eye. “Patching an eye will not affect the vision ∫∫ Eliminate glare by moving mirrors and in any way and will not delay recovery to shiny objects. any significant degree. The brain always ∫∫ Heighten contrasts using paint or colored tells both eyes to move at once,” he said. tape to mark light switches, doorways, In addition, it doesn’t matter which eye is and steps. patched. “Patch whichever eye helps you ∫∫ Use large print. Newspapers, books, clocks, to see better,” he advises. telephone dials, calendars, playing cards — virtually everything printed may be Persistent nystagmus is more difficult to available in a large-print version. treat. Treating nystagmus may improve ∫∫ Be practical: carry a flashlight to movies; and diminish oscillopsia, find out where the bathroom is ahead of and may also improve the sense of time when eating out. equilibrium as well. First-line treatment ∫∫ Learn to ask for help when you need it. of nystagmus involves maximizing a While hard at first, this is also very practical. person’s spectacle prescription. Dr. According to Dr. Frohman, both diplopia Van Stavern and Dr. Hedges agree that and nystagmus can affect your navigation medications for ongoing nystagmus may and balance. “Added to a little bit of leg be tried, but, often do not work well. weakness or gait imbalance, and these Surgery may be an option but is rarely vision problems can increase one’s safety used to treat nystagmus. In difficult cases, risk,” Dr. Frohman said. He notes that prisms, surgery, and Botox patching one eye affects a person’s depth injections can be used.According to Dr. perception, so a cane or other mobility Hedges, work is being done on optical aid may be essential to prevent accidents. devices to stabilize the jiggling visual environment of people with nystagmus.

Vision Problems | 5 Other resources and organizations to Low-Vision Aids contact about living successfully with low Many optical devices have specific uses. vision include: One may be best for reading e-mail, ∫∫ American Foundation for the Blind another for watching movies, and yet 800-AFB-LINE (800-232-5463) another for cooking or reading a book. www.afb.org Magnifying devices are a case in point. A ∫∫ American Nystagmus Network higher power magnifier provides a larger www.nystagmus.org image but a smaller field of view. A lower ∫∫ American Printing House for the Blind power magnifier will have a larger field, ∫∫ 800-223-1839 with a smaller image. Your needs dictate www.aph.org which is more important, and using your ∫∫ magnifier often will make it more and more Lighthouse International 800-829-0500, TTY: 212-821-9713 helpful to you. Be patient — everyone has www.lighthouse.org individual adjustment periods. ∫∫ The Low Vision Gateway One of the more popular visual aids is www.lowvision.org the closed circuit television (CCTV) ∫∫ Low Vision Center which can magnify a number of things 301-951-4444 — including photographs, letters, book www.lowvisioninfo.org pages, even the labels on medicine bottles ∫∫ The National Association for — onto a television screen. Some CCTVs Visually Handicapped are freestanding, with a monitor that sits 800-677-9965 on a platform. Others are plugged into www.navh.org your television and use its screen. ∫∫ The National Federation of the Blind Your computer and smart phone can 410-659-9314 also be modified in dozens of ways. www.nfb.org Smartphones, tablets, and most computer ∫∫ The National Eye Institute operating systems offer voice command 301- 496-5248 software like Siri, and programs that www.nei.nih.gov translate text into voice and vice versa. ∫∫ North American Text magnifiers are also available. The Neuro-Opthalmology Society low Vision Gateway, at www.lowvision. 952-646-2037 org, has an extensive list of computer www.nanosweb.org/home.cfm programs for people with low vision. ∫∫ Public Broadcasting Service’s Photographer Flo Fox recommends that Descriptive Video Service people with visual problems register at 617-300-3600 their local post office for free mailing. www.wgbh.org/dvs

Vision Problems | 6 The National Multiple Scerosis Society (“Society”) is proud to be a source of information on multiple sclerosis related topics. The information provided is based on professional advice, published experience, and expert opinion, but does not constitute medical or legal advice. For specific medical advice, consult a qualified physician. For specific legal advice, consult a qualified attorney. The Society does not endorse products, services or manufacturers. Such names appear here solely because they are considered helpful information. The Society assumes no liability for the recipient’s use of any product or service mentioned. The Society does not independently verify whether the information provided by each service provider is accurate. The Society undertakes no responsibility to verify whether the service provider is appropriately licensed and certified and has applicable insurance coverage. Early and ongoing treatment with an FDA-approved therapy can make a difference for people with multiple sclerosis. Learn about your options by talking to your healthcare professional and contacting the National MS Society at nationalMSsociety.org or 1-800-344-4867.

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© 2015 National MS Society. All rights reserved. ES6034 9/15 Vision Problems | 7 Three Most Common Eye Disorder in MS Relapses Nystagmus Optic Neuritis Diplopia Inflammation in Inflammation of the Inflammation in the the Brainstem or Optic Nerve Brainstem or Cerebellum Cerebellum Oscillopsia (experience Main Symptoms Blurred vision Double vision of the world appearing to “wiggle”)

Pain with the eye Dizziness, movement; blind Dizziness; jerky unsteadiness; crossed- Other Symptoms spots; loss of contrast eye movements; or outward turning sensitivity; poor color unsteadiness eye vision

Neurologist or eye Neurologist or eye Neurologist or Consult doctor doctor eye doctor

Outline doorway, stairs and steps Mounted with high-contrast magnifiers; markings; increase large-print Self-Help Patch one eye lighting levels; books and other eliminate glare by low-vision aids; moving mirrors and medication other shinny objects

Remission Good Good Good Expectation

Recurrence Possible Possible Possible

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