title: Visual pathway axonal loss in benign multiple sclerosis:  a longitudinal study.
abstract: BACKGROUND
  Benign multiple sclerosis (MS), traditionally defined as Expanded Disability Status Scale (EDSS) score ≤3 and ≥15-year disease duration, is thought to follow a milder clinical course. We determined the extent of visual pathway axonal loss by optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) thickness in a benign MS cohort and examined the relation to vision and quality of life (QOL).
  
  
  METHODS
  In this longitudinal study of vision in MS at 3 academic centers, a subset of patients with EDSS, visual function, OCT, and QOL assessments was analyzed. Low- and high-contrast letter acuity was performed to assess visual function. RNFL thickness was determined using time-domain OCT. QOL scales included the 25-Item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) and Short Form-36 Health Survey.
  
  
  RESULTS
  Among 68 patients (135 eyes) studied longitudinally, 13 (26 eyes) had benign MS using criteria of EDSS score ≤3 and ≥15-year disease duration. Benign MS eyes had as much RNFL thinning (-3.6 μm, P = 0.0008 vs baseline, paired t test) as typical MS eyes (-3.3 μm, P < 0.0001). Both groups had significant low-contrast acuity loss. History of optic neuritis (ON) was more frequent in benign MS (69% vs 33% of eyes). History of ON distinguished benign vs typical MS (P = 0.002) and correlated with RNFL thickness at baseline (P = 0.002) and disease duration (P = 0.03) but not EDSS (P = 0.32, logistic regression). NEI-VFQ-25 scores were also worse for benign MS, accounting for age (75 ± 21 vs 88 ± 11, P = 0.005).
  
  
  CONCLUSIONS
  Patients with benign MS have RNFL axonal loss that is as marked as that of typical MS and have reduced vision and QOL. While overall neurologic impairment is mild, visual dysfunction, not well captured by the EDSS, accounts for a substantial degree of disability in benign MS.
authors.affiliation: Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Galetta
authors.forename: Jennifer
authors.initials: J
authors.lastname: Graves
authors.forename: Lauren S
authors.initials: LS
authors.lastname: Talman
authors.forename: Deacon J
authors.initials: DJ
authors.lastname: Lile
authors.forename: Elliot M
authors.initials: EM
authors.lastname: Frohman
authors.forename: Peter A
authors.initials: PA
authors.lastname: Calabresi
authors.forename: Steven L
authors.initials: SL
authors.lastname: Galetta
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Balcer
mesh_terms: D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009103:Multiple Sclerosis / Q000175:diagnosis / Q000503:physiopathology*; D011446:Prospective Studies; D011788:Quality of Life; D012165:Retinal Ganglion Cells / Q000473:pathology; D011795:Surveys and Questionnaires; D041623:Tomography, Optical Coherence / Q000379:methods*; D014792:Visual Acuity; D014795:Visual Pathways / Q000473:pathology / Q000503:physiopathology*