Internuclear Ophthalmoplegia

Physical Examination

• Noticeable ataxic handshake upon greeting, indicating potential cerebellar or sensory tract involvement.

• The patient may be in a wheelchair, suggesting significant mobility issues or advanced disease.

• Acuity - Decreased visual acuity can be noted, which might be a result of optic neuritis, or optic atrophy.

• Observation of internuclear ophthalmoplegia, which may frequently be bilateral in MS cases, indicating a lesion in the medial longitudinal fasciculus.

• Ophthalmoscopic examination may reveal optic atrophy, which is a common finding in long-standing cases of MS.

• Presence of any other cranial nerve palsies, varying as per the area of demyelination.

• Examination of the upper and lower limbs may reveal upper motor neurone signs, such as spasticity and weakness.

• Cerebellar examination might reveal the 'DANISH' signs - Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, and Hypotonia.

Investigations

• Laboratory Tests:

  • Blood tests: These are performed to rule out other conditions with similar symptoms. It might include tests for vitamin B12 deficiency, Lyme disease, or autoimmune markers.

  • Cerebrospinal fluid (CSF) analysis: It is done to detect abnormal levels of certain substances associated with MS, such as oligoclonal bands. CSF can also be tested for other conditions like infections or inflammation that can cause similar neurological symptoms.

• Imaging Studies:

  • Magnetic Resonance Imaging (MRI) of the brain and spinal cord: This is the most important imaging study in diagnosing MS. MRI can show areas of demyelination (plaques or lesions) in the brain and spinal cord.

  • MRI with gadolinium contrast: The contrast can help distinguish active from inactive lesions. Active lesions take up the contrast, indicating inflammation or recent demyelinating activity.

  • Optical Coherence Tomography (OCT): This imaging test can be used to assess the thickness of the retina and the optic nerve, which may be reduced in MS due to optic neuritis.

Management

• General Management:

  • Multidisciplinary approach: Managing MS requires a team approach, involving neurologists, physiotherapists, occupational therapists, nurses, and mental health professionals.

  • Lifestyle modifications: Encourage regular physical activity, balanced diet, and adequate rest.

  • Rehabilitation services: Physical therapy to improve mobility and strength, occupational therapy to help with daily tasks, and speech therapy for speech and swallowing problems.

  • Psychological support: Addressing emotional health is crucial. Offer counselling or referral to a psychologist for cognitive and emotional issues.

• Medical Management:

  • Acute relapses: High-dose corticosteroids, like methylprednisolone, are often used to reduce the severity and duration of MS relapses.

  • Disease-modifying therapies: These aim to reduce the frequency and severity of relapses and slow the progression of disease. This includes medications like interferon beta, glatiramer acetate, dimethyl fumarate, fingolimod, alemtuzumab, natalizumab, and ocrelizumab.

  • Symptom management: Medications may be used to manage specific symptoms of MS, such as muscle spasticity (baclofen, tizanidine), neuropathic pain (gabapentin, amitriptyline), fatigue (amantadine), and bladder symptoms (intermittent self-catheterization or tolterodine).