A Rare Presentation of Multiple Sclerosis

A 12-year-old girl with multiple sclerosis was presented with complaints of double vision primarily associated with straight and right gaze. She had an error of refraction, her slit lamp ophthalmic examination and fundus examination were normal. The right eye’s motion was restricted on extraocular muscle evaluation and no change in vision was found. Nodular foci were observed in MRI, suggestive of optic neuritis and demyelination. Ocular coherence tomography revealed nerve fiber thinning of both eyes with 58% of asymmetry, indicating preclinical optic neuritis. In addition to this, she had imbalance and paresthesia. She had no history of viral illness, fever, headache or nausea. The Kurtzke Expanded Disability Status Scale score was 3.0 with mild disability in three functional systems.

Results

Usually, 2.7-5% of children younger than 16 years are affected by multiple sclerosis. The common manifestations include gait disorders, sensory and motor deficits, brainstem disturbances and optic neuritis. The patient had thinning of retinal nerve fibre layer consistent with optic neuritis but without relative afferent pupillary defect and right eye inflammation. Retinal nerve fibre layer thinning was were observed without clinical and MRI findings. However, the presenting symptoms were also consistent with sixth nerve palsy, which is rare in pediatric cases. Clinicians must have a high index of suspicion and must include ocular coherence tomography with MRI during such presentations.

Usually, 2.7-5% of children younger than 16 years are affected by multiple sclerosis. The common manifestations include gait disorders, sensory and motor deficits, brainstem disturbances and optic neuritis. The patient had thinning of retinal nerve fibre layer consistent with optic neuritis but without relative afferent pupillary defect and right eye inflammation. Retinal nerve fibre layer thinning was were observed without clinical and MRI findings. However, the presenting symptoms were also consistent with sixth nerve palsy, which is rare in pediatric cases. Clinicians must have a high index of suspicion and must include ocular coherence tomography with MRI during such presentations.

#1. What should be the diagnosis of this patient?

a) Sixth Nerve Palsy

a) Sixth Nerve Palsy

b) Multiple Sclerosis

b) Multiple Sclerosis

c) Optic Neuritis

c) Optic Neuritis

d) All of the above

d) All of the above

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