Serial Gadolinium-enhanced MRI in untreated patients with acute optic neuritis: implications for natural history

The socioeconomic consequences of optic neuritis with and without multiple sclerosis: a controlled national study

OBJECTIVES

Optic neuritis (ON) often precedes multiple sclerosis (MS). MS is associated with a significant socioeconomic burden. However, the burden of ON with and without MS before and after its diagnosis has never been calculated.

METHODS

Using complete national records from the Danish National Patient Registry (1998-2006), we identified 1677 patients with ON and compared them with 6708 randomly selected citizens matched for age, sex and geography. A societal perspective is taken towards the cost analyses. Costs included in the analysis are those of the health sector, including all contacts with primary and secondary sectors, and the use and costs of drugs. Productivity losses included labour supply and income. All social transfer payments were also calculated.

RESULTS

Patients with ON had higher rates of contact with healthcare services, medication use and income from employment, all of which incurred a higher socioeconomic cost. Employed patients had lower income than control subjects. The total annual excess costs relative to matched controls were €3501 for ON patients and €9215 for patients with a dual diagnosis of ON and MS. The ON and ON+MS patients received an annual mean excess social transfer income of €1175 and €4619. ON/ON+MS patients presented social and economic consequences up to 8 years before diagnosis, and these increased after the diagnosis was established.

CONCLUSIONS

ON, especially if combined with a diagnosis of MS, has a significant socioeconomic consequence for the individual patient and for society. Productivity losses are a far more important economic factor than health sector costs.

Role of magnetic resonance imaging within diagnostic criteria for multiple sclerosis

The diagnosis of multiple sclerosis (MS) has been improved in recent decades with the incorporation of paraclinical investigations in diagnostic workup. In the last 15 years, magnetic resonance imaging (MRI) has become an especially valuable tool for supporting MS diagnosis, and specific imaging criteria became fundamental to the guidelines for the diagnosis of MS published in 2001 by an international panel (IP). The new IP criteria include MRI evidence of dissemination in space and time, making it possible to diagnose MS after a single clinical episode. This review considers current evidence concerning the reliability of the new IP criteria for the diagnosis of relapsing-onset MS, discusses strengths and weaknesses of the criteria, and outlines areas which may need modification or should be the focus of future research directed toward improving diagnostic accuracy. It also makes practical recommendations when using MRI and the IP criteria in MS diagnosis, especially in patients with clinically isolated syndromes or atypical presentations. The IP criteria are timely and concrete and introduce an important concept to MS diagnosis. Future modifications, based on emerging evidence, should further facilitate their implementation and improve their accuracy.

Ophthalmology update for primary practitioners. Part I. Update on optic neuritis

Optic neuritis is a common cause of acute visual loss. It is typified by sudden onset of visual impairment and pain with eye movements, followed by spontaneous recovery of vision over several months. Pathologically, optic neuritis is an acute demyelinating event affecting the optic nerve. Objective physical findings are typically few, including an afferent pupillary defect or Marcus-Gunn pupil, whereas subjective psychophysical findings abound (ie, diminished central visual acuity, color vision, decreased contrast sensitivity, and visual field abnormalities). These characteristics have made the diagnosis of optic neuritis based solely on clinical grounds disquieting to practitioner and patient alike. In addition, the fact that optic neuritis is often associated with multiple sclerosis as the first clinical manifestation of disease gives further reason for both patient and physician anxiety. The serious nature of visual loss and the consequences of making the diagnosis of optic neuritis has given rise to extensive testing and expensive treatments. This review is intended to explore our current state of knowledge with regard to (1) clinical presentation, (2) ancillary testing, (3) therapeutic intervention, and (4) associated disease, specifically the risk for multiple sclerosis in the patient who presents with an acute optic neuritis. Finally, a suggestion guide for informing the patient and addressing his or her concerns will be presented.

Expression of specific chemokines and chemokine receptors in the central nervous system of multiple sclerosis patients

Chemokines direct tissue invasion by specific leukocyte populations. Thus, chemokines may play a role in multiple sclerosis (MS), an idiopathic disorder in which the central nervous system (CNS) inflammatory reaction is largely restricted to mononuclear phagocytes and T cells. We asked whether specific chemokines were expressed in the CNS during acute demyelinating events by analyzing cerebrospinal fluid (CSF), whose composition reflects the CNS extracellular space. During MS attacks, we found elevated CSF levels of three chemokines that act toward T cells and mononuclear phagocytes: interferon-gamma-inducible protein of 10 kDa (IP-10); monokine induced by interferon-gamma (Mig); and regulated on activation, normal T-cell expressed and secreted (RANTES). We then investigated whether specific chemokine receptors were expressed by infiltrating cells in demyelinating MS brain lesions and in CSF. CXCR3, an IP-10/Mig receptor, was expressed on lymphocytic cells in virtually every perivascular inflammatory infiltrate in active MS lesions. CCR5, a RANTES receptor, was detected on lymphocytic cells, macrophages, and microglia in actively demyelinating MS brain lesions. Compared with circulating T cells, CSF T cells were significantly enriched for cells expressing CXCR3 or CCR5. Our results imply pathogenic roles for specific chemokine-chemokine receptor interactions in MS and suggest new molecular targets for therapeutic intervention.

Ocular manifestations of neurological disease

This review covers the recent developments in the diagnosis, natural history and treatment of several common neuro-opthalmological disorders, such as optic neuritis, pseudotumour cerebri and nonarteritic anterior ischaemic optic neuropathy. It also deals briefly with the effects on the eye of the ataxias and antiepileptic drugs.