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Open Access Peer-reviewed

Investigation of Ocular Manifestation in Patients Diagnosed with Multiple Sclerosis Based on the Manifestation and Demographic and Geographic Data

Zahra Janamiri , Yousef Moghimi Boldaji, Fardis Mosayebian
American Journal of Medical Case Reports. 2018, 6(3), 47-49. DOI: 10.12691/ajmcr-6-3-2
Published online: April 21, 2018

Abstract

Introduction: Multiple sclerosis (MS) is an autoimmune inflammatory condition which attacks and demyelinate central nervous system neurons with variable degree which causes significant disability in these patients. In this study, we plan to investigate ocular manifestation and prevalence of these symptoms in patients diagnosed with MS. Methods: We have enrolled 100 patients with confirmed diagnosis of MS, in a retrospective study from neurology clinic of a private hospital in Tehran, from 2015 to 2016. We have reviewed the thorough neurological examination and visual assessment of these patients. Also, demographic data of these patients were recorded for further analysis. We have performed statistical analysis using SPSS version 16 and Stuent T-test and Chi-square test for variables analysis. Results: Of all patients, 85 cases were female and 15 were male, with mean age of 35.2 years. We have found atrophy of the disc followed by optic neuritis in 32% and 19% respectively. Also, retrobulbar neuritis and papillitis were among less common manifestations, counting as 13% and 8% respectively. Most of the ocular manifestation were consistent with some demographic and geographic factors, such as age (most common in patients under 34 years old), female gender and patients not living in city areas. Also, patients with their disease initially started less than 22 years showed increased frequency of nystagmus and optic disc atrophy, while defect in color vision were more common in patients with initial disease initiation after 22 years old (P value < 0.05). Conclusion: Patients with MS may have various presentations of neurological abnormalities, which ocular manifestations is one of the most important and initial warning signs. We have found that optic disc atrophy and optic neuritis are among the most common presentations of MS, and neurologists should consider demographic and geographic parameters of patients.

1. Introduction

Multiple sclerosis (MS) is an immune-mediated inflammatory disease that attacks myelinated axons in the central nervous system (CNS), destroying the myelin and the axon in variable degrees. 1 In most cases, the disease follows a relapsing-remitting pattern, with short-term episodes of neurologic deficits that resolve completely or almost completely. 2 It is diagnosed based on clinical findings and supporting evidence from ancillary tests, such as magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid (CSF) examination. 3 Immuno-modulatory agents consists the therapy for the underlying immune disorder and management of symptoms, as well as non-pharmacologic treatments, such as physical and occupational therapy. MS may present itself with various types of neurological manifestation, ranging from CNS to spinal cord disorders. 4 However, ocular manifestation is one of the most terrifying and initial presentation of MS in these patients, thus we plan to investigate ocular manifestation and prevalence of these symptoms in patients diagnosed with MS, as well as relevant demographic and geographic factors.

2. Methods

From 2015 to 2016, we have retrospectively entered patients referred to neurology clinic of a private hospital in Tehran with confirmed diagnosis of MS. We have excluded patients with underlying active malignancy at their MS evaluation, history of previous cranial radiotherapy, patients with history of ocular surgery and any relevant ophthalmologic problems, patients with missing data regarding their thorough neurological examination as well as ocular examination including fundoscopy and patients with missing data of their geographical status and demographic data were excluded from study. Diagnosis of these patients was confirmed using neuro-imaging modalities such as MRI and also CSF analysis in suspected patients. We have utilized SPSS version 16 for statistical analysis, as well as Student T-test and Chi-square test for evaluation of variables.

3. Results

After performing the exclusion criteria, we have enrolled 100 patients; consist of 85 females with mean age of 35.8 (ranged between 18.2 years old and 42.1 years old) and 15 males with mean age of 33.4 years (ranged between 25.3 years old and 39.2 years) in this retrospective study. We have found atrophy of the disc followed by optic neuritis in 32% and 19% respectively. Also, retrobulbar neuritis and papillitis were among less common manifestations, counting as 13% and 8% respectively. Most of the ocular manifestation were consistent with some demographic and geographic factors, such as age (most common in patients under 34 years old), female gender and patients not living in city areas. Also, patients with their disease initially started less than 22 years showed increased frequency of nystagmus and optic disc atrophy, while defect in color vision were more common in patients with initial disease initiation after 22 years old. (P value < 0.05) Also, we have found that patients more than 26 years old suffered more diplopia than patients less than 26 years old, which was statistically significant. (P value < 0.05).

4. Discussion

Prevalence of MS in United States of America is reported to be from 58 to 95 per 100000 in general population. Presentation of MS varies based on ethnicity, geographical features and also genetic of the patients. 5 Some patients have a predominance of cognitive changes, while others present with prominent ataxia, hemiparesis or paraparesis, depression, or visual symptoms. 6 Classic symptoms of MS are found in literature as follow: sensory loss which is an early complaint, spinal cord motor and autonomic symptoms, cerebellar symptoms (manifested as Charcot triad of dysarthria, nystagmus and intention tremor) and optic neuritis. 7 Besides neurological abnormalities, constitutional and psychological symptoms may occur. Also, less common manifestations such as seizure, aphasia and other paroxysmal symptoms have been reported with less than 5% frequency. 8, 9 Due to highly variable neurological manifestations, neurologists should always consider other possible diagnosis, such as spinal cord neoplasms, acute disseminate encephalomyelitis (ADEM), Schilder disease, sarcoidosis, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), transverse myelitis, as well as infectious processes of spinal cord and underlying collagen vascular disease involving CNS vasculature. 10, 11, 12 MS is diagnosed based on combination of neurological abnormalities, as well as imaging modalities combine with blood tests and CSF analysis. Also, the 2010 McDonald criteria allow diagnosis of MS even with a first clinical episode. Plaque enhancement on cerebral hemispheres as well as in nerve tracts and basal ganglia and in cerebellum is highly appreciated on conventional MRI, since other neuro-imaging modalities such as Computed Tomography (CT) scan and ultrasonography of the cranial fossa will not help physician’s capabilities. 13, 14 Also, other techniques such as evoked potentials and electroencephalography (EEG) are other techniques used in diagnosis of MS. We have found that patients in MS who referred to our neurology clinic, exhibit ocular manifestation as disc atrophy followe by optic neuritis, retrobulbar neuritis and also papillitis as their most common ocular manifestation and these symptoms should promote physician’s attention to suspect MS as the underlying disease. Also, we have found that geographical and demographic data are strongly correlate with these symptoms.

5. Conclusion

Patients with MS may have various presentations of neurological abnormalities, which ocular manifestations is one of the most important and initial warning signs. We have found that optic disc atrophy and optic neuritis are among the most common presentations of MS, and neurologists should consider demographic and geographic parameters of patients.

References

[1]  Polman, C.H., Reingold, S.C., Banwell, B., Clanet, M., Cohen, J.A., Filippi, M., Fujihara, K., Havrdova, E., Hutchinson, M., Kappos, L., Lublin, F.D., “Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria,” Annals of neurology, 69(2). 292-302. 2011.
In article      View Article  PubMed
 
[2]  Lublin, F.D., Reingold, S.C., “Defining the clinical course of multiple sclerosis results of an international survey,” Neurology, 46(4). 907-11. 1996.
In article      View Article  PubMed
 
[3]  Cortese, I., Chaudhry, V., So, Y.T., Cantor, F., Cornblath, D.R., Rae-Grant, A., “Evidence-based guideline update: Plasmapheresis in neurologic disorders Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology,” Neurology, 76(3). 294-300. 2011.
In article      View Article  PubMed
 
[4]  Calabresi, P.A., Kieseier, B.C., Arnold, D.L., Balcer, L.J., Boyko, A., Pelletier, J., Liu, S., Zhu, Y., Seddighzadeh, A., Hung, S., Deykin, A., “Pegylated interferon beta-1a for relapsing-remitting multiple sclerosis (ADVANCE): a randomised, phase 3, double-blind study,” The Lancet Neurology, 13(7). 657-65. 2014.
In article      View Article
 
[5]  Valenzuela, R.M., Pula, J.H., Garwacki, D., Cotter, J., Kattah, J.C., “Cryptococcal meningitis in a multiple sclerosis patient taking natalizumab,” Journal of the neurological sciences, 340(1). 109-11. 2014.
In article      View Article  PubMed
 
[6]  Gold, R., Kappos, L., Arnold, D.L., Bar-Or, A., Giovannoni, G., Selmaj, K., Tornatore, C., Sweetser, M.T., Yang, M., Sheikh, S.I,, Dawson, K.T., “Placebo-controlled phase 3 study of oral BG-12 for relapsing multiple sclerosis,” New England Journal of Medicine, 367(12). 1098-107. 2012.
In article      View Article  PubMed
 
[7]  Cohen, J.A., Coles, A.J., Arnold, D.L., Confavreux, C., Fox, E.J., Hartung, H.P., Havrdova, E., Selmaj, K.W., Weiner, H.L., Fisher, E., Brinar, V.V., “Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised controlled phase 3 trial,” The Lancet, 380(9856). 1819-28. 2012.
In article      View Article
 
[8]  Nielsen, N.M., Westergaard, T., Rostgaard, K., Frisch, M., Hjalgrim, H., Wohlfahrt, J., Koch-Henriksen, N., Melbye, M., “Familial risk of multiple sclerosis: a nationwide cohort study,” American journal of epidemiology, 162(8). 774-8. 2005.
In article      View Article  PubMed
 
[9]  Kampman, M.T., Brustad, M., “Vitamin D: a candidate for the environmental effect in multiple sclerosis–observations from Norway,” Neuroepidemiology, 30(3). 140-6. 2008.
In article      View Article  PubMed
 
[10]  Williamson, D.M., Noonan, C.W., Henry, J.P., Wagner, L., Indian, R., Lynch, S.G., Neuberger, J.S., Schiffer, R., Trottier, J., Marrie, R.A., “Peer Reviewed: The Prevalence of Multiple Sclerosis in 3 US Communities,” Preventing chronic disease, 7(1). 2010.
In article      PubMed  PubMed
 
[11]  Bonhomme, G.R., Waldman, A.T., Balcer, L.J., Daniels, A.B., Tennekoon, G.I., Forman, S., Galetta, S.L., Liu, G.T., “Pediatric optic neuritis Brain MRI abnormalities and risk of multiple sclerosis,” Neurology, 72(10). 881-5. 2009.
In article      View Article  PubMed
 
[12]  Seddighi, A.S., Seddighi, A., Behrouzian, S., Nikouei, A., “Simultaneous Presentation of Cerebellopontine Angle Pleomorphic Xanthoastrocytoma and Malignant Melanoma in a Known Case of Neurofibromatosis 1; Probable Role of BRAF Gene: A Case Report and Review of Literature,” International Journal of Cancer Management, 10(7). 2017.
In article      View Article
 
[13]  Filippi M, Yousry TA, Alkadhi H, Stehling M, Horsfield MA, Voltz R. Spinal cord MRI in multiple sclerosis with multicoil arrays: a comparison between fast spin echo and fast FLAIR. Journal of Neurology, Neurosurgery & Psychiatry. 1996 Dec 1; 61(6): 632-5.
In article      View Article  PubMed
 
[14]  Seddighi, A., Nikouei, A., Seddighi, A.S., Zali, A.R., Tabatabaei, S.M., Sheykhi, A.R., Yourdkhani, F., Naeimian, S., “Peripheral nerve injury: a review article,” International Clinical Neuroscience Journal, 3(1). 1-6. 2016.
In article      
 

Published with license by Science and Education Publishing, Copyright © 2018 Zahra Janamiri, Yousef Moghimi Boldaji and Fardis Mosayebian

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Zahra Janamiri, Yousef Moghimi Boldaji, Fardis Mosayebian. Investigation of Ocular Manifestation in Patients Diagnosed with Multiple Sclerosis Based on the Manifestation and Demographic and Geographic Data. American Journal of Medical Case Reports. Vol. 6, No. 3, 2018, pp 47-49. http://pubs.sciepub.com/ajmcr/6/3/2
MLA Style
Janamiri, Zahra, Yousef Moghimi Boldaji, and Fardis Mosayebian. "Investigation of Ocular Manifestation in Patients Diagnosed with Multiple Sclerosis Based on the Manifestation and Demographic and Geographic Data." American Journal of Medical Case Reports 6.3 (2018): 47-49.
APA Style
Janamiri, Z. , Boldaji, Y. M. , & Mosayebian, F. (2018). Investigation of Ocular Manifestation in Patients Diagnosed with Multiple Sclerosis Based on the Manifestation and Demographic and Geographic Data. American Journal of Medical Case Reports, 6(3), 47-49.
Chicago Style
Janamiri, Zahra, Yousef Moghimi Boldaji, and Fardis Mosayebian. "Investigation of Ocular Manifestation in Patients Diagnosed with Multiple Sclerosis Based on the Manifestation and Demographic and Geographic Data." American Journal of Medical Case Reports 6, no. 3 (2018): 47-49.
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[1]  Polman, C.H., Reingold, S.C., Banwell, B., Clanet, M., Cohen, J.A., Filippi, M., Fujihara, K., Havrdova, E., Hutchinson, M., Kappos, L., Lublin, F.D., “Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria,” Annals of neurology, 69(2). 292-302. 2011.
In article      View Article  PubMed
 
[2]  Lublin, F.D., Reingold, S.C., “Defining the clinical course of multiple sclerosis results of an international survey,” Neurology, 46(4). 907-11. 1996.
In article      View Article  PubMed
 
[3]  Cortese, I., Chaudhry, V., So, Y.T., Cantor, F., Cornblath, D.R., Rae-Grant, A., “Evidence-based guideline update: Plasmapheresis in neurologic disorders Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology,” Neurology, 76(3). 294-300. 2011.
In article      View Article  PubMed
 
[4]  Calabresi, P.A., Kieseier, B.C., Arnold, D.L., Balcer, L.J., Boyko, A., Pelletier, J., Liu, S., Zhu, Y., Seddighzadeh, A., Hung, S., Deykin, A., “Pegylated interferon beta-1a for relapsing-remitting multiple sclerosis (ADVANCE): a randomised, phase 3, double-blind study,” The Lancet Neurology, 13(7). 657-65. 2014.
In article      View Article
 
[5]  Valenzuela, R.M., Pula, J.H., Garwacki, D., Cotter, J., Kattah, J.C., “Cryptococcal meningitis in a multiple sclerosis patient taking natalizumab,” Journal of the neurological sciences, 340(1). 109-11. 2014.
In article      View Article  PubMed
 
[6]  Gold, R., Kappos, L., Arnold, D.L., Bar-Or, A., Giovannoni, G., Selmaj, K., Tornatore, C., Sweetser, M.T., Yang, M., Sheikh, S.I,, Dawson, K.T., “Placebo-controlled phase 3 study of oral BG-12 for relapsing multiple sclerosis,” New England Journal of Medicine, 367(12). 1098-107. 2012.
In article      View Article  PubMed
 
[7]  Cohen, J.A., Coles, A.J., Arnold, D.L., Confavreux, C., Fox, E.J., Hartung, H.P., Havrdova, E., Selmaj, K.W., Weiner, H.L., Fisher, E., Brinar, V.V., “Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised controlled phase 3 trial,” The Lancet, 380(9856). 1819-28. 2012.
In article      View Article
 
[8]  Nielsen, N.M., Westergaard, T., Rostgaard, K., Frisch, M., Hjalgrim, H., Wohlfahrt, J., Koch-Henriksen, N., Melbye, M., “Familial risk of multiple sclerosis: a nationwide cohort study,” American journal of epidemiology, 162(8). 774-8. 2005.
In article      View Article  PubMed
 
[9]  Kampman, M.T., Brustad, M., “Vitamin D: a candidate for the environmental effect in multiple sclerosis–observations from Norway,” Neuroepidemiology, 30(3). 140-6. 2008.
In article      View Article  PubMed
 
[10]  Williamson, D.M., Noonan, C.W., Henry, J.P., Wagner, L., Indian, R., Lynch, S.G., Neuberger, J.S., Schiffer, R., Trottier, J., Marrie, R.A., “Peer Reviewed: The Prevalence of Multiple Sclerosis in 3 US Communities,” Preventing chronic disease, 7(1). 2010.
In article      PubMed  PubMed
 
[11]  Bonhomme, G.R., Waldman, A.T., Balcer, L.J., Daniels, A.B., Tennekoon, G.I., Forman, S., Galetta, S.L., Liu, G.T., “Pediatric optic neuritis Brain MRI abnormalities and risk of multiple sclerosis,” Neurology, 72(10). 881-5. 2009.
In article      View Article  PubMed
 
[12]  Seddighi, A.S., Seddighi, A., Behrouzian, S., Nikouei, A., “Simultaneous Presentation of Cerebellopontine Angle Pleomorphic Xanthoastrocytoma and Malignant Melanoma in a Known Case of Neurofibromatosis 1; Probable Role of BRAF Gene: A Case Report and Review of Literature,” International Journal of Cancer Management, 10(7). 2017.
In article      View Article
 
[13]  Filippi M, Yousry TA, Alkadhi H, Stehling M, Horsfield MA, Voltz R. Spinal cord MRI in multiple sclerosis with multicoil arrays: a comparison between fast spin echo and fast FLAIR. Journal of Neurology, Neurosurgery & Psychiatry. 1996 Dec 1; 61(6): 632-5.
In article      View Article  PubMed
 
[14]  Seddighi, A., Nikouei, A., Seddighi, A.S., Zali, A.R., Tabatabaei, S.M., Sheykhi, A.R., Yourdkhani, F., Naeimian, S., “Peripheral nerve injury: a review article,” International Clinical Neuroscience Journal, 3(1). 1-6. 2016.
In article