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Fall 2009

Visual Imaging Expands Clinical Vision for MS

As with any medical condition, managing multiple sclerosis requires piecing together a dynamic array of diagnostic tests, physical exams and self-reported symptoms. Ari Green, M.D., assistant director of the UCSF Multiple Sclerosis Center and director of the Department of Neurology's neurodiagnostics center, believes that advances in retinal imaging add an important piece to the puzzle.

"There is a population of neurons in the inner retina that are frequently subject to injury in MS," he says. "Fortuitously, the axons arising from these cells are isolated from other white matter pathways, allowing us to study structure and function at the same time."

The ability to obtain clear images of the retina — and join those findings to a complete clinical, social and personal evaluation — is one of the advantages of a focused center like the one at UCSF.

Advanced Diagnostics

Even before imaging, visual exams at the neurodiagnostics center take MS diagnosis and follow-up evaluation beyond routine clinical care. Technicians test visual modalities that include color, low contrast and low luminance vision, and visual fields. Other tests, including enhanced visual evoked potentials, gather important functional information about the retina that a standard evaluation does not.

As for imaging, the neurodiagnostics center uses next-generation retinal imaging techniques and technologies to amplify other findings and help determine which ones are ripe for clinical trials.

"By using these techniques to detect subclinical injury, we hope to help follow MS patients without waiting for them to decline neurologically," says Green.

Studies have suggested this is possible, but Green points out that because there is still much to be learned, his colleagues at the MS center use the full array of neurodiagnostic tools to help identify patients who may need more aggressive treatment — especially those with unchecked disease that threatens their vision.

Light Waves Deliver Greater Clarity

One particularly promising technique being tested by the center is retinal imaging with optical coherence tomography (OCT), which provides extremely high-resolution, cross-sectional images of biological tissue.

"The improved clarity helps us detect injury in the retina at a resolution of a few micrometers, and now we are even able to develop 3-D images that allow us to directly measure the volume of segmented layers of the retina," says Green.

UCSF physicians have also used OCT on a number of occasions to aid in patient diagnosis. In multiple instances, they have identified central serous retinopathy, rather than optic neuritis, when a patient was experiencing subacute visual problems. In another case, during a workup for MS, a patient was found to have a retinal hemorrhage that indicated a clotting disorder, which can mimic MS.

Equally important, this advanced imaging is providing new insights into all types of demyelinating disease.

"What drives the disease comes into question because we can see inflammation in an anatomical area with no myelin," says Green. "We are left with the question, Why is there an aberrant immune response, absent the myelin, which is supposed to be driving it?"

As Green and colleagues develop this modality further and standardize protocols, the center's ultimate goal is to train and educate others, so they can interpret and perform the tests.

"Our preference is always to co-manage these patients in active collaboration with their referring physicians," says Green.

For more information, contact Ari Green, M.D. at (415) 353–2707 or (415) 353–4003.

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