CSR and MS

[Alicious]

In 2007 I was diagnosed with Central Serous Retinopathy. Basically, it is a leakage in the retina caused by who knows what that resolves over time. It has left me with vision that cannot be corrected beyond 20/30 in my right eye.

There has been no change in it for two years, and my vision should be stable in that eye. My ophthalmologist and neurologist insist it has nothing to do with MS, and based on the biology involved I have no reason to doubt them.

Here's the thing--lately when I exert myself more than usual (yardwork, etc.), that eye gets blurrier and light feels much brighter. If I wait a few hours, it goes away. It's not supposed to do that based on the CSR damage, but neither the ophthalmologist nor the neuro have ever seen evidence of optic neuritis during exams.

I will of course bring this up with the eye doc, but I was wondering if there could be an MS connection here or if it is something only my docs could speculate on?

[MrsBones]

My first case of ON was mis-dxd as CSR. My optho didn't see anything else wrong,either. Thankfully, he sent me to a retinologist, who disagreed that it was CSR and believed it to be ON. He sent me to a neuro-op who dx'd the ON and gave me a preliminary dx of MS.

Question...Did angiograghy confirm?

The first thing I must say is that ON isn't always visible. Sometimes, there is little to no visual indication upon exam.

Second, your neuro isn't trained to do anything at all with your eyes, even if it could be MS related, other than to send you to the optho. S/he agreeing doesn't really mean too much.

Third, Uhthoff's (which is what you're describing) is typical of ON. It is the same essentially as heat intolerance, with slowed nerve conduction due to demyelination being slowed further by elevated body temp. In this case, the vision is effected because it is the optic nerve that is damaged.



http://medical-dictionary.thefreedic...ff%27s+symptom

http://emedicine.medscape.com/article/1214270-overview

Of course, I can't say you were mis-dx'd, too, but Uhthoff's would make one suspicious that you had ON at one time or another.

At this point, if you did, damage is done and there's nothing you can do about it. Now knowing you have MS, you'll be on the look out for its sx so that any future possible bouts ON can be treated appropriately.

[Alicious]

MrsBones, thank you so much for this additional info for me to mull over. I have never had an angiography; I'm pretty sure I'd remember if I had, which of course makes me wonder why not...a question for the opthalmologist, of course.

The Uhthoff's is new (past few months), and I will definitely bring it up with the neuro. If it means that the damage is done I understand, but I want to make sure that is really what is going on, you know?

Thank you again!

[Redwings]

Hi Alicious:
I'll start at the point at which everyone agrees: CSR has no known relationship to MS. Although there isn't complete agreement about what causes it, there is enough known about the mechanics of it to know that it's a completely different process than MS. And it's that difference between CSR and MS visual causes and effects that gives clues about what might be going on with your vision.

It's reasonable to think that your right eye's vision should be stable two years after CSR. But that's not always the case, because the recurrence rate of CSR in the same eye is about 30%. As you've noticed, though, the visual effects you're describing aren't typical of CSR, which doesn't wax and wane within a few hours. The significance of the clues is that the visual effects are 1) new (which doesn't in itself rule out a recurrence of CSR) and 2) different (which steers away from CSR as being the prime suspect) in a formerly stable eye.

As MrsBones pointed out, what you're describing is very Uhthoff's-ish. That's a different type of neuronal process than the disruptions of CSR and is characteristic of MS. At this point, things start to get a bit more complicated and open to some speculation.

Thanks to new technologies, it's been known now for several years that -- in people with MS who have never had a known episode of optic neuritis -- there are abnormalities in the various visual pathways that run from the retina, across the brain, to the visual cortex. So it isn't correct to assume that all visual problems in MS are due only to the optic nerves or to optic neuritis. Visual problems can originate along those pathways anywhere in the brain.

The fact that your ophthalmologist and neurologist have never seen evidence of optic neuritis at past exams is irrelevant to a new problem that's developed since then. That's like saying, "I got hit by a bus this morning. I have a terrible headache and trouble walking, and I can't figure out why because, when I saw my doctor yesterday, he said I was fine."

Further, a full 2/3 of cases of optic neuritis occur in the portion of the nerve behind the eye (retrobulbar), where inflammation can't be seen ophthalmoscopically. Even hot, acute active cases that wipe out vision often can't be seen. Hence the saying about ON: The doctor can't see anything and the patient can't see anything.

It's possible that your ophthalmologist could look at your optic nerve during one of your episodes of blurry vision and not see a problem. Mild and subclinical cases of neuronal degeneration and/or inflammation just aren't visible on examination. So an ophthalmoscopic exam can't be used to absolutely rule things out.

Since what you're describing sounds like Uhthoff's, Uhthoff's is a characteristic of MS and you are already known to have MS, it's quite reasonable to believe that what you're experiencing with your vision in the post-CSR eye is connected to MS. Other kinds of testing will have to determine how much is due to MS and how much might be retinal. (For example, how much is the previous retinal damage -- part of those pathways that run all the way to the brain -- contributing to your symptoms and how significant is it in the overall picture?)

Fortunately, a quick OCT can tell within a few minutes whether your CSR has recurred (no dilating, no angiogram). An OCT can also identify thinning of the retinal nerve fiber layer, which is an indication of the atrophy of those visual pathways through the brain. A VEP can give more information about what's happening in those visual pathways. Even more helpful would be if there were previous tests done to compare to. It might not be possible to completely localize where the problem originates, but specialized testing can at least rule out recurrent CSR.

As MrsBones also pointed out, once the damage is done, it's done. Subclinical ON (if that's what you have) isn't treated. What's more important is that it's a marker to be used to asses the status of your MS overall. So it's worth bringing up with both your neurologist and your ophthalmologist.

[Alicious]

Thank you, Redbones. I was having this issue the last time my ophthalmologist saw me and I had him explain to me the difference between CSR and ON, but I thought it was just my dry eyes causing the variances in my vision so i didn't bring it up. (D'oh!) As I've paid more attention to the the actual symptoms and circumstances, I've come to realize that it's not dryness, but something else, and after chatting with you two, I agree that it sounds very much like Uhthoff's. I am fortunate in that heat hasn't affected my symptoms yet, so it didn't occur to me.

I very much got the impression from the docs that if there was ON that they would have seen it, but I'm guessing that I misunderstood them saying that they didn't see anything and I had no symptoms of it so there is no reason to look further as meaning that they would see it if it were there. (Is that sentence convoluted enough?)

I've been debating leaving my ophthalmologist for other reasons, so I will call my neuro's office tomorrow and ask for the name of an ophtho who is familiar with MS patients. Mine has only a passing familiarity, and I'd like to be examined by someone with more knowledge oin the topic.

I completely get that if there is damage in there due to MS that it's a done deal, but I definitely want to know if that is going on if only so I can know, process it, deal with it, and find something else to worry about.

Thank you for your post--it was very informative and helpful. I haven't looked into ON much because I've assumed I don't have it, and while I still may not have it, it's time to do my research all the same!

[MrsBones]

Might be worthwhile to look into a neuro-op, if possible. As Redwings points out, MS can contribute to visual problems in more ways than one. An optho can certainly be helpful, but IMPO, a neuro op might be more familiar, given their specialty, with the many ways MS can effect the vision.

That said, they are few and far between. A new optho who is recommended by your neuro as a person familiar with MS may be your best option.

[Alicious]

I'm in the Denver area, and Googling I came across more than one neuro-op in the metro area. I'm not sure I really need that big of a gun, but it's nice to know they are out there. I'll start with my own neuro and see who they recommend.

Again, thanks to you both! xoxo