What Does MS Eye Pain Feel Like?

Vision and Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease that can affect the brain, spinal cord, and optic nerves.  A large portion of the central nervous system is devoted to vision, eye movements, and visual processing.  It’s no surprise then that patients with multiple sclerosis often have a variety of visual symptoms that can impact overall function and quality of life.

MS and Optic Neuritis

One of the most common manifestations, and frequently the initial presenting symptom, of MS is optic neuritis. Optic neuritis develops when there is inflammation of the optic nerve – the “cables” that connect the eyes and the brain. The symptoms of optic neuritis vary based on the patient.

Classic optic neuritis in MS is characterized by one-sided loss of vision that is heralded by eye pain. This pain occurs because the inflammation affecting the optic nerve extends to the covering of the optic nerve.  The pain typically will develop in or around the eye and may worsen or only be present with eye movements. The pain can be a vague ache, often mistaken as a headache, or more severe pain that may be unrelenting or even stabbing in quality. Shortly after developing the pain, patients may develop vision loss. This too can range in terms of severity. Some patients may present with blurry vision or changes in their color vision, while others may present with more severe missing vision or be unable to see entirely from one eye.

Vision changes usually reach their peak within a day or two and can recover over the following weeks to months. Most patients with MS related vision loss will have good recovery after an attack even without treatment. However, acute treatment is recommended, and MS patients with optic neuritis are often given high doses of steroids to accelerate the rate of visual recovery or shorten the duration of symptoms so that patients can return to their daily activities such as working and driving sooner. Many patients do notice residual blurry vision or changes in color vision. Patients with a history of optic neuritis may also notice that stress, exercise, fever, and higher-temperature environments (i.e. hot shower, jacuzzi) can cause vision in their affected eye to become temporarily worse, a symptom dubbed “Uhthoff’s phenomenon” reflecting prior damage to the optic nerve. Symptoms resolve quickly to baseline when the body cools down.  Disease-modifying therapies are drugs that suppress the immune system in the long-term and are recommended for patients with MS. The goal of these treatments is to keep the disease at bay and protect the optic nerves from any further attacks of vision loss.

Additional Symptoms Affecting Vision

Not all vision problems in MS are optic neuritis, and not all eye pain is optic neuritis. Floaters, for example, often described as painless tiny black spots in vision that move with the eyes occur as the gel within the eye, the vitreous, begins to deteriorate over time and  is not a common manifestation of MS. Symptoms such as eye redness or discharge are seen more commonly in ophthalmologic conditions such as dry eye, conjunctivitis, and glaucoma and should be evaluated by a comprehensive ophthalmologist.

MS lesion involvement of visual pathways deeper in the brain can cause visual field loss or areas of missing or dimmer vision in both eyes. Lesions in the brainstem or cerebellum can often affect eye movement and cause double vision or diplopia, which in MS is characterized by seeing two of the same objects when both eyes are open, but improvement when covering either eye. Internuclear ophthalmoplegia (INO) is a commonly seen condition in MS causing double vision. In an INO, the horizontal eye movements are no longer linked together, and one eye may lag behind the other when looking in different directions. Patients may describe frank double vision because of this, or they may just feel that their eyes ‘lag behind’ their head movement. Fatigue is the most common symptom of multiple sclerosis and can manifest in many ways. Occasionally, the fatigue of MS can cause underlying misalignments of the eyes called strabismus to become more apparent to patients.

MS patients with brainstem or cerebellar lesions can also develop nystagmus, which is an involuntary, rhythmic shaking movement of the eye. Patients with nystagmus will complain of shaking of their vision, a phenomenon known as “oscillopsia”. There are many therapies that can lessen these visual symptoms in MS that patients can discuss with their MS doctor or ophthalmologist. Patients may benefit from prism glasses or even surgery to fix misaligned eyes causing double vision. There are also medications or specific glasses that can improve coordination of eye movements or dampen nystagmus.

Additionally, while migraine headaches can occur in any individual, they are more common in patients with MS. Migraine headaches often start with a ‘visual aura’ which is characterized by momentary blurry or flashing vision, or glittering spots in vision known as a scintillating scotoma. The pain of migraine headache can sometimes be difficult to differentiate from optic neuritis, but the symptoms of light or sound sensitivity and nausea or vomiting can suggest migraine. Persistent vision loss should aways be brought to the attention of a healthcare provider.

Where to Turn When Experiencing MS-Related Eye Pain

MS -related vision changes can be very distressing for patients and can cause significant short and long-term changes to their lives.  All MS patients should have regular comprehensive eye exams by an ophthalmologist or by a neuro-ophthalmologist when needed. Neuro-ophthalmologists who diagnose and treat visual manifestations of neurologic disease have special tools to examine the visual system of the brain. A neuro-ophthalmology visit will frequently include advanced tests like perimetric visual fields and optical coherence tomography (OCT) – a specialized picture that can detect microscopic changes to the optic nerve or retina not seen by the naked eye.

Visual symptoms in MS can be distressing, but understanding how MS can manifest in the eye helps with early detection and management. If you experience symptoms such as painful vision loss, blurry or missing vision, or double vision we recommend reaching out to your doctor to facilitate a rapid evaluation and potential treatment.