What are ocular motility abnormalities in multiple sclerosis (MS)?

Updated: Feb 21, 2019
  • Author: Fiona Costello, MD, FRCP; Chief Editor: Hampton Roy, Sr, MD  more...
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Patients with MS frequently present with ocular motility abnormalities on examination, although they may not report related symptoms. Demyelinating lesions in the brainstem and/or cerebellum can lead to ocular misalignment caused by gaze palsies or damage to the ocular motor cranial nerves. The resulting ocular misalignment can cause horizontal, vertical, and/or oblique diplopia.

Involvement of the brainstem and/or cerebellum can also cause damage to neural integrators in the CNS (medial vestibular nuclei, nucleus prepositus hypoglossus, interstitial nuclei of Cajal, and superior vestibular nuclei), [40] which help stabilize images on the retina during eye and head movements. This can lead to nystagmus, which is defined as repetitive to-and-fro involuntary eye movements initiated by slow drifts of the eye. [41] Patients with nystagmus may note a perception that their world is moving, termed oscillopsia, and report blurred vision, imbalance, dizziness, and spatial disorientation. [41]

Patterns of nystagmus can be localizing from an anatomical perspective and therefore help facilitate the diagnosis of MS. Nystagmus should not be confused with saccadic abnormalities that impair steady fixation in patients with MS. [40, 41] Furthermore, patients with MS may report focusing difficulties when watching objects in motion or when they themselves are in motion. These particular symptoms may arise from smooth pursuit abnormalities and impaired suppression of the vestibule-ocular reflex. [40]

Efferent visual pathway lesions may be challenging to identify in patients with MS and even more difficult to treat. To alleviate symptoms of diplopia, Fresnel prisms can be used temporarily to allow correction of ocular misalignment in primary position during the time required for recovery. In patients with persistent large-angle ocular deviations, ground-in prisms or, in rare cases, strabismus surgery may be feasible treatment options.

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