Oscillopsia and double vision in MS
Do you have jumpy vision? In this newsletter I discuss a case and its treatment
Case study
Dear Professor Giovannoni,
I am 46 years of age and have had MS for over 20 years. I am now very disabled and can only walk with someone supporting me due to severe instability. I also have a tremor and poor memory. My biggest problem is poor vision because my eyes are very jumpy. I also have double vision when looking left or right or in the distance. Is there anything that can be done for my dancing eyes?
Prof G’s Opinion
This patient has severe cerebellar involvement that affects their balance, coordination, speech, eye movements and cognition. If you want to know more about how MS can affect the cerebellum, I suggest you read the following two Newsletters.
This person is likely to have nystagmus (jerky eye movements) when looking left and right or up and down. In addition, she is likely to have square-wave jerks when in the neutral position.
Square wave jerks are involuntary, horizontal, brief eye movements that interrupt fixation. Each square wave jerk consists of an initial slow eye movement that moves the centre of your vision away from the intended position of fixation. This is followed by a second faster eye movement in the opposite direction to restore fixation. The square-wave jerks can occur in all directions and are not coordinated between the two eyes. This results in the images projected onto the retinae not being overlaid or synchronised and causes double vision or jumpy vision (oscillopsia). This is particularly problematic when looking into the distance and is called distance esotropia (an esotropia is a type of squint).
Whether or not square-wave jerks cause double vision depends on how severe it is and whether or not a patient sees using both eyes (binocular vision). Some patients may only use one eye for vision due to having had a squint as a child (amblyopia), loss of vision in one eye from severe optic neuritis or loss of vision due to another cause. Ambylopia is when the brain never learns to process visual information from both eyes together and suppresses vision from one eye.
Sometimes when I look at the back of the eye with an ophthalmoscope, I may see small square jerks of the optic disc. These are too small to see with the naked eye and are not associated with jumpy vision or oscillopsia. They are called micro square wave jerks. However, micro square wave jerks are a sign of early cerebellar involvement.
Other eye movement problems that occur with cerebellar involvement are the slow initiation of eye movements (hyopmetric saccades), the over or undershoot when looking at an object (saccadic dysmetria) and slow eye movements (slow saccades). These make it very difficult for people with cerebellar involvement to watch sports such as tennis and play computer games; they can’t track rapidly moving targets.
If the eye movement problem is severe, it may affect visual reaction times and makes driving dangerous. This is a common cause for pwMS failing their driving license assessment.
There are some treatments for pwMS and oscillopsia, and blurred vision. Pharmacological, optical, and surgical treatments are available, depending on the characteristics of the nystagmus and the severity of the associated visual symptoms.
Sometimes pwMS find a neutral position of gaze that then minimises the oscillopsia, and they can function normally. Similarly, covering one eye often works. If this is the case, I recommend alternate eye patching to ensure both eyes are given time to work.
Sometimes prisms for your glasses or special contact lenses can work. These bend the light coming into the eyes, reducing double vision. Other things that help are using the high contrast mode on your computer or mobile device and using low-vision mode with large fonts. Increasing the size of your computer monitor may help. Many pwMS learn that a magnifying reading glass helps, and they can continue reading.
Oscillopsia can be fatigue-related and only comes on when you are tired. To deal with this, take frequent rests. Interestingly, a recent patient who started fampridine to help improve their walking ability told me it had suppressed her oscillopsia. I am not surprised as the mechanism underlying walking problems in MS are likely to be similar to those affecting vision. Despite this anecdote, I cannot prescribe fampridine off-label for oscillopsia on the NHS.
The following are pharmacological treatments that may work. Please note these are prescription drugs and call come with potential side effects.
Downbeat nystagmus can be treated with 4-aminopyridine, 3,4-diaminopyridine, or clonazepam.
Upbeat nystagmus can be reduced with memantine, 4-aminopyridine, or baclofen.
Torsional nystagmus may respond to gabapentin.
Acquired pendular nystagmus (no fast and slow phase, both phases have a similar velocity) in PWM can be partially suppressed by gabapentin or memantine.
Although rare in pwMS, acquired periodic alternating nystagmus (the slow and fast phase change direction) is often entirely suppressed by baclofen; memantine can be effective in refractory cases.
Seesaw nystagmus can be reduced with clonazepam or memantine.
Other treatment options for nystagmus include botulinum toxin injections into the extraocular muscles or behind the eye. This paralyses the eye muscles and fixes the eye in a neutral position.
In the future, we may have electrical devices in order to negate the visual consequences of nystagmus noninvasively. To the best of my knowledge, these are not yet available.
This Newsletter makes it seems that we have sorted the treatment of cerebellar eye sign, but unfortunately not. Although these drugs can help, they are often associated with side effects, mainly sedation, and they often don’t correct the problem entirely.
I rarely manage cerebellar eye problems, as they involve complex ophthalmic measurements and interventions. Therefore, I give patients self-management advice on what they can do for themselves, and I then refer them to a low-vision aid clinic run by ophthalmologists.
I would be interested to know how many of you have problems with oscillopsia or double vision looking in the distance. How many of you have seen an ophthalmologist for these problems and received treatment? Are there things I have missed out on?
Review article: Thurtell & Leigh. Treatment of nystagmus. Curr Treat Options Neurol. 2012 Feb;14(1):60-72.
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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.
lve had double vision - told i had some nystagmus. i have multiple eye diagnoses - on top of bilateral optic neuritis. i found trevor wickens ms gym eye exercises really helpful - very quick results - use them to top up if it comes back. just an easy idea!
I have an off topic question for you Prof -
Is it right that the dental reference system doesnt take into consideration how dental how infections affect the average pwms? It is right that they should not take into consideration that we cannot tolerate a dental infection even before there is " at least visible facial swelling" because of the neurological and relapse trigger effect?
To elaborate: i have quite bad neuro damage even though i am stable on tysabri. If i get an elevated temperature - anything past 37 degrees say due to infection, or get any slight infection/virus such as a tooth infection i become virtually unable to walk and i get bppv. I become unbearingly cognitively impaired.
How do I explain to other health professionals such as my dentist/nhs maxilo surgery provider that they can't treat me like a normal person? That if they do i literally wont be able to walk/talk/sleep/think?
How do you explain to people that your brain starts metaphorically boiling and your brain operating system goes blue screen?
Do they not have a higher duty of care for patients with chronic idleness?
What they call a non emergency- i.e. a small infection- is a very big deal to pwms.
I've been told (shouted at) today by the nhs surgery I was referred to by my dentist that basically im a queue jumping hypocondriac problem patient when i tried to ask the manager to please highly consider me on their cancellation list.