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Optic neuritis with possible multiple sclerosis — MSRA MCQ

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HardMRIOptic neuritis with possible multiple sclerosisMSRA

A 32-year-old woman is reviewed in general practice after ophthalmology assessment for 8 days of painful reduction in vision in her left eye. The ophthalmologist confirmed unilateral optic neuritis. Her visual acuity is now improving following treatment, and there is no bilateral visual loss, myelopathic symptom, fever, systemic inflammatory feature or recent infection. She has no previous neurological episodes. MRI brain and orbits, arranged by ophthalmology, shows several ovoid periventricular and juxtacortical T2 hyperintense lesions. The radiology report states that the appearances are suggestive of demyelination but do not establish a diagnosis. She asks whether she has multiple sclerosis and whether she needs another MRI immediately. What is the most appropriate next management plan?

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Correct answer: D — Refer to a consultant neurologist for diagnostic assessment incorporating the clinical history, MRI findings and further investigations if indicated

Explanation lettering: E = shown as A · A = shown as B · B = shown as C · C = shown as D · D = shown as E

This woman has ophthalmologist-confirmed isolated optic neuritis, a typical focal demyelinating syndrome in a person under 50 years old. Her MRI lesions increase the possibility of multiple sclerosis (MS), but MRI appearances alone do not establish MS. Diagnosis requires specialist integration of the clinical course, examination, MRI evidence and, where needed, laboratory or cerebrospinal-fluid findings using the McDonald criteria. NICE specifically recommends referral to a consultant neurologist after confirmed isolated optic neuritis. A is premature because neither optic neuritis nor MRI lesions alone establish relapsing-remitting MS. B is plausible because aquaporin-4 and MOG testing, and sometimes cerebrospinal-fluid analysis, may be relevant in selected cases; however, their selection and interpretation belong within specialist diagnostic assessment rather than being a prerequisite to referral. D may become appropriate after specialist assessment if diagnostic criteria are not met and a surveillance strategy is agreed, but it inappropriately delays neurology review now. E fails because visual recovery does not remove the need to assess the future risk of MS and alternative inflammatory demyelinating disorders.

Reference: Multiple sclerosis in adults: management (NG220), recommendations (Last updated 03 June 2026) — https://www.nice.org.uk/guidance/ng220/chapter/Recommendations