La radiologia medica

https://doi.org/10.1007/s11547-019-01073-1

EMERGENCY RADIOLOGY

MRI of acute optic neuritis (ON) at the first episode: Can we predict

the visual outcome and the development of multiple sclerosis (MS)?
Michaela Cellina1   · Chiara Floridi2 · Cristina Rosti3 · Marcello Orsi1 · Marta Panzeri4 · Marta Pirovano5 ·
Matteo Ciocca5 · Giancarlo Oliva1 · Daniele Gibelli6

Received: 8 May 2019 / Accepted: 7 August 2019

© Italian Society of Medical Radiology 2019

Abstract
Aim  Our aim was to assess MRI findings in the acute phase of ON and their correlation with visual acuity at presentation,
visual outcome (VO) and MS development, to analyze a possible correlation between lesions number and diagnosis, and to
assess correlation between orbits MRI and OCT.
Materials and methods  We retrospectively studied 37 patients, who presented to our Emergency Department with an ON
first episode from January 2015 to January 2017. Patients underwent immediately a complete neuro-ophthalmological
evaluation, blood test, CSF analysis. MRI of brain, orbits, cervical spine was executed within 7 days from ON onset. Brain
MRI was classified as: normal, non-specific, suspected demyelination, lesions with dissemination in space and time. Optic
nerves findings were localized in three sites (intra-orbital, canalicular and chiasmal) and classified as: normal, STIR- altera-
tion, altered contrast enhancement. Patients underwent neuro-ophthalmological follow-up and MRI at 6 months to assess
VO (complete recovery, partial recovery, deficit persistence). Another follow-up at 1 year was performed to identify MS or
clinically isolated syndrome (CIS).
Results  64.8% patients received a diagnosis of MS; 35% of CIS. Lesions of the optic nerve were found in 65.8%. We observed
statistically significant correlation between brain MRI pattern and diagnosis and between lesions number and diagnosis.
We observed a statistically significant correlation between orbital MRI pattern and optical coherence tomography (OCT)
results. MRI brain findings correlate with development of MS. MRI brain features and lesions number can predict the risk
of MS conversion.

Keywords  Optic neuritis · Multiple sclerosis · Optical coherence tomography · Magnetic resonance · MRI · Visual outcome

Introduction

Optic neuritis (ON) is an acute inflammatory demyelinat-

* Michaela Cellina
michaela.cellina@asst‑fbf‑sacco.it
1
Radiology Department, ASST Fatebenefratelli Sacco, Piazza
Principessa Clotilde 3, 20123 Milan, Italy
2
Radiology Department, San Paolo Hospital, Via A Di Rudinì
8, 20142 Milan, Italy
3
Department of Radiology, Civil Hospital, Corso Milano 19,
27029 Vigevano, Italy
4
Radiology Department, IRCCS Ospedale San Raffaele, Via
Olgettina 23, 20121 Milan, Italy
5
Neurology Department, ASST Fatebenefratelli Sacco, Piazza
Principessa Clotilde 3, 20123 Milan, Italy
6
Department of Biomedical Sciences for Health, Università
degli Studi di Milano, Via Mangiagalli 31, 20121 Milan,
Italy
ing disorder of the optic nerve, primarily an isolated phe-
nomenon or secondarily associated with other neurological
diseases such as neuromyelitis optica or multiple sclerosis
(MS) and represents the most common cause of visual loss
in young adults [1].
The most common symptoms include unilateral, subacute
visual loss with variable severity, retrobulbar pain worsened
with eye movement, dyschromatopsia, without systemic or
other neurological symptoms.
The onset of ON is mostly monophasic, but it can also
sometimes be polyphasic with recurrent relapses.
ON is most frequent in females (F:M = 3:1) and is usually
diagnosed in young adults (20–45 years), with a mean age
at onset of 36 years.

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ON may be the initial presentation in ~ 20% of patients
affected by MS, and up to 50% of patients with MS may
experience during their life [2].
ON is normally a self-limiting event, and recovery of
visual acuity typically occurs within the first few weeks
from the onset, even though persistent visual impairment
has been observed in some patients [3, 4].
Visual recovery after an episode of ON is variable and
difficult to predict [5]. It has been reported that patients
who have symptoms at onset have a poorer prognosis,
and this is mainly related to the fact that vision rees-
tablishment starts earlier compared with patients with
mild symptoms, but restoration of visual function is still
possible [6, 7]. Corticosteroid treatment hastens recov-
ery following ON, but this does not improve final visual
function.
Magnetic resonance imaging (MRI) may help ON diag-
nosis as it allows detecting optic nerve inflammation, to
rule out differential diagnoses, and to predict the risk for
developing MS [1, 4].
The application of MRI in the assessment of optic
nerve damage in a single episode of acute ON has been
rarely performed [4], and its role in predicting the prog-
nosis of visual impairment and visual outcome after ON
is not clear [4, 6–10].
Optical coherence tomography (OCT) is a noninvasive
imaging technique used in ophthalmology to visualize the
layers of the retina. It allows the depiction of unmyeli-
nated central nervous system axons within the retina, the
so-called retinal nerve fiber layer (RNFL), and provides a
measurement of its thickness (micron-scale). The RNFL
thickness is used as a noninvasive biomarker of neurode-
generation and axonal loss in MS [11, 12].
Our aim was to assess brain and orbital MRI findings
of patients with a first attack of acute ON, and their cor-
relation with visual acuity at presentation, visual recov-
ery, MS development and a possible correlation between
orbits MRI pattern and RNFL on OCT.
Methods and materials
This retrospective study has been approved by our Insti-
tutional Review Board (Institutional Review Board Area
1 Milan; reference number: 2018/ST/116). All procedures
performed in studies involving human participants were
in accordance with the ethical standards of the institu-
tional and national research committee and with the 1964
Helsinki Declaration and its later amendments. Informed
consent was obtained from all individual participants
included in the study.
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La radiologia medica
Patients
We retrospectively revised the ophthalmological, neuro-
logical and imaging data of patients who were admitted
to our Emergency Department (ED) with the first episode
of acute ON from January 2015 to January 2017 (N = 85).
The exclusion criteria were: patients aged < 18 years;
previous episodes of ON; history of MS or optic neu-
romyelitis (NMO); patients affected by known ophthal-
mological diseases; patients affected by immunological/
infective disorders; patients with previous neurological
events; patients with family history of Leber hereditary
optic neuropathy; lack of complete ophthalmological, neu-
rological, imaging data; time between symptoms onset and
presentation > 14 days; time between ED arrival and MRI
execution > 14 days; MRI executed in other Institutions;
lack of follow-up data; clinical follow-up < 1 year.
We therefore included in our study 37 patients (age
range 21–57 years; mean age 33 years), 26 females and
11 males. Twenty had right ON, 13 had ON in the left
eye, and 4 had bilateral ON, for a total of 41 affected eyes.
After the arrival, each patient underwent a complete
ophthalmological examination, including fundoscopic
examination, visual acuity assessment, visual field and
OCT, brain and orbits unenhanced computed tomography,
according to the protocol of our Emergency Department,
to exclude intracranial and orbital abnormalities, blood
tests to exclude infective/autoimmune causes of ON and to
test AQP4 antibodies myelin oligodendrocyte glycoprotein
(MOG) IgG and cerebrospinal fluid (CSF) collection for
detection of the oligoclonal bands, as previously described
[13].
Following the neuro-ophthalmological confirmation
of the diagnosis of ON, steroid therapy was administered
intravenously within 24 h from the patient access (meth-
ylprednisolone 1 g/day for 5 days, followed by a low-dose
steroid oral regimen for 15 days).
MRI
MRI of brain, orbits, cervical spine was performed after
the beginning of the steroid treatment, within 7 ± 6 days
from ON onset on the same 1.5 T MRI scanner (Achieva,
Siemens Forchheim, Germany) with the acquisition pro-
tocol shown in Table 1 with intravenous administration of
contrast medium (Gadovist, 0.1 mmol/kg) with an 8-chan-
nel head coil [13].
Dorso-lumbar MRI was added in three patients, accord-
ing to the Neurologist’s indication.
Steroid treatment was started after the diagnosis of ON,
before MRI execution.
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Table 1  MRI acquisition protocol

Brain T1 SE sag PD + T2 TSE tra Dark fluid sag Diffusion tra T1 vibe 0.6*

Sequence 2D 2D 3D 2D 3D
Orientation Sagittal Transversal Sagittal Transversal Transversal
Suppression – – IR FS Q-FS
B value 0/500/1000
FoV (mm * mm) 240 × 240 240 × 195 280 × 245 280 × 280 250 × 180
Matrix (pixel * pixel) 230 × 256 187 × 384 218 × 256 139 × 174 290 × 448
Voxel size (mm * mm * mm) 1.0 × 0.9 × 5. 0 1.0 × 0.6 × 0.5 1.1 × 1.1 × 1.0 2.0 × 1.6 × 4.0 0.6 × 0.6 × 0.6
TR (ms) 377 3900 6000 5000 8.16
TE (ms) 8.1 15/132 359 98 3.15
TI (ms) – – 2200 – –
Flip angle 90° 150° – – 15°
Scan time (mm:ss) 03:00 04:10 07:02 04:55 04:29
Orbits T2 TSE cor FS T2 TSE tra FS SPACE STIR tra T1 SE FS tra* T1 SE FS cor

Sequence 2D 2D 3D 2D 2D
Orientation Coronal Transversal Transversal Transversal Coronal
Suppression FS FS IR FS FS
FoV (mm * mm) 210 × 210 210 × 177 220 × 198 190 × 190 240 × 218
Matrix (pixel * pixel) 358 × 512 302 × 512 218 × 256 160 × 320
Voxel size (mm * mm * mm) 0.6 × 0.4 × 0.3 0.6 × 0.4 × 0.3 0.9 × 0.9 × 0.9 1.2 × 0.6 × 3.0 1.3 × 0.9 × 3.0
TR (ms) 4230 3130 3800 550 400
TE (ms) 115 77 213 17 8.1
TI (ms) – – 160 – –
Flip angle 150° 150° – 90° 90°
Scan time (mm:ss) 04:07 04:12 05:51 03:37 04:26
Cervical spine T2 TSE sag T1 TSE sag T2 STIR sag T1 TSE sag FS*

Sequence 2D 2D 2D 2D
Orientation Sagittal Sagittal Sagittal Sagittal
Suppression – – IR FS
FoV (mm * mm) 250 × 250 250 × 250 300 × 300 250 × 250
Matrix (pixel * pixel) 256 × 256 218 × 256 208 × 320 250 × 384
Voxel size (mm * mm * mm) 1.0 × 1.0 × 3.0 1.1 × 1.0 × 3.0 1.4 × 0.9 × 3.0 1.0 × 0.7 × 4.0
TR (ms) 4000 550 4440 550
TE (ms) 90 9.4 103 12
TI (ms) – – 160 –
Flip angle 150° 90° – 150°
Scan time (mm:ss) 02:58 02:51 04:04 04:39

After the acquisition of sequence without contrast medium on brain, orbits, cervical spine; Gadobutrol was intravenously administered
(0.1 mmol/kg); 5 min after contrast administration the axial T1 FS on orbits was started, then the coronal T1 FS on orbits, the T1 FS on the cer-
vical spine and finally the VIBE to study the brain
SE spin echo, PD proton density, TSE turbo spin echo, IR inversion recovery, FS fat saturation, FoV field of view, TR repetition time, TE echo
time, TI inversion time

Imaging exams were transferred to the MRI workstation
(Leonardo, Siemens, Forchheim, Germany) and revised
by two experienced neuroradiologists in consensus, who
were blinded to all clinical and ophthalmologic informa-
tion such as the affected eye, laboratory results and final
clinical diagnoses.
Brain MRIs patterns were classified as (0) normal, (1)
non-specific, if millimetric hyperintensities in T2 and
FLAIR with location and morphology not typical for demy-
elinating lesions were observed, (2) lesion with MS-like
shape, localized in typical MS sites—periventricular, jux-
tacortical, infratentorial, or spinal cord—with dissemination

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in space [14], (3) or lesions with MS-like shape, localized in
typical MS sites—periventricular, juxtacortical, infratento-
rial, or spinal cord—with dissemination in space and coex-
istence of gadolinium-enhancing and non-enhancing lesions
[15, 16]. The number of brain and spinal cord lesions was
recorded.
Optic nerves MRIs were reported as (1) normal, (2)
STIR—alteration without contrast enhancement (CE), (3)
STIR signal abnormalities + CE. Optic nerves pathologic
findings were localized into three sites [intra-orbital (IO),
canalicular (CA) and chiasmal (CH)], and the length of
altered signal or CE was measured in cm.
Visual acuity
Visual acuity was measured at patients’ arrival, according to
Snellen chart (decimal). Light perception and motus manus
(mm) were assigned a decimal visual acuity of 0.
The degree of visual acuity was further divided into
three groups: severe deficit (mm—4/10), intermediate
deficit (5–7/10), slight deficit (8/10, 9/10). Each patient
was followed-up for at least 12 months (mean follow time:
16 ± 4 months).
OCT
OCT test was acquired using the same machine (Spectralis
version 6.3.2, Eye Explorer Software 1.6.1.0, Heidelberg
Engineering™, Heidelberg, Germany), after mydriasis
induced with 1% tropicamide.
OCT produces a cross-sectional image of the peripapil-
lary retina which is color-coded and shows the temporal,
superior, nasal, inferior and temporal sections on the same
image.
The software automatically recognizes the retinal nerve
fiber layer (RNFL) layer, measures the RNFL thickness
along the scan and reports the results on a graphic display
showing the RNFL thickness (in μm). We considered the
average global value of RNFL and classified OCT results
into four groups, according to its value: (1) normal; (2)
increased; (3) reduced; (4) borderline.
Follow‑up
Ophthalmological evaluation including visual acuity
assessment was executed at 6 months to establish the visual
outcome. The timing of 6 months for follow-up has been
decided in accordance with previous study that described
dominant visual recovery within this period [17, 18].
Visual outcome was classified into four groups: (1) com-
plete visual recovery: visual acuity back to the value before
ON, (2) partial visual recovery: recovery of visual acuity
of at least 50% compared to the value before ON, (3) stable
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deficit: recovery of visual acuity < 50% compared to the
value before ON, or persistence of the visual deficit, as dur-
ing ON episode, (4) visual worsening.
Patients were followed-up from a neurological point of
view for at least 1 year (range 12–29 months) and were diag-
nosed as MS or clinically isolated syndrome (CIS).
CIS or MS diagnosis was based on revised McDonald
criteria [16].
Statistical analysis
Statistical analysis was performed using SPSS (IBM SPSS
Statistics for Windows, Version 22.0. Armonk, NY: IBM
Corp). Pearson chi-square test for categorical variables
was used to assess the correlation between brain MRI pat-
terns and visual acuity, visual outcome and diagnosis, and
between orbits MRI patterns and visual acuity, visual out-
come and diagnosis. Logistic regression model was applied
to variables with p < 0.05.
We then performed Mann–Whitney U test to assess the
correlation between the lesions number and the diagnosis,
applied the logistic regression model and finally performed
ROC curve analysis, and to evaluate the correlation between
orbital MRI pattern and extension of the altered signal of
the optic nerve.
Kruskal–Wallis test was performed to assess possible cor-
relation between orbits MRI pattern and RNFL thickness
at OCT.
Results
Brain MRIs were classified as follows: (1) normal in 9
patients out of 37 patients; (2) millimetric hyperintensities
in T2 and FLAIR with location and morphology not typical
for demyelinating lesions in 9 out of 37 patients; (3) lesions
with MS-like shape, localized in typical MS sites with dis-
semination in space without contrast enhancement in 13 out
of 37 patients and (4) lesions with MS-like shape, localized
in typical MS sites with dissemination in space and coexist-
ence of gadolinium-enhancing and non-enhancing lesions
in 6 out of 37 patients.
MS-like shape lesions number range was: 0–25, with a
mean number of 8 ± 2.
Optic nerves MRIs were reported as: (1) normal in 14 out
of 41 eyes (34%); (2) STIR- alteration without CE in 13 out
of 41 eyes (31.7%); STIR signal abnormalities + CE in 14 out
of 41 eyes (34.1%). Optic nerves pathologic findings were
localized into the IO segment in 9 out of 27 eyes with signal
abnormalities (33.3%); into the CA segment in 16 out of 27
eyes (59.2%); IO + CA in 2 out of 27 eyes (7.4%), whereas
no localization was observed in the CH segment. The length
of altered STIR signal or CE measured as follows: extension
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range: 0.5–2 cm; mean extension: 1.5 ± 0.2 cm. The extent

of signal alterations was greater in the optic nerves show-
ing contrast enhancement (p = 0.03; Fig. 1). Three patients
showed spinal cord lesions at both cervical and dorsal level;
one patient showed one cervical spinal cord lesion.
Visual outcome was classified as: complete recovery in
12 out of 37 patients (32.4%), partial recovery in 16 out of
37 patients (43.2%) and deficit persistence in 9 out of 37
patients (24.3%). No patients in our case series presented
a worsening in visual acuity at 6-months follow-up. Mean
visual acuity at follow-up was 7 ± 1/10.
Twenty-five patients (67.5%) received a diagnosis of MS;
12 patients (32.4%) received a diagnosis of CIS; in our group
no patients received a diagnosis of NMO. All patients with
spinal cord lesions received a diagnosis of MS.
We observed statistically significant correlation (p = .001)
between brain MRI pattern and diagnosis [p = .004; OR 45.5 Fig. 2  1: SM; 2: CIS. The box plot shows the correlations between
(95% CI 3.48–594.6)]. the lesions number and final diagnosis
Lesions number was statistically correlated with final
diagnosis (p = .001; OR 1.342; 95% CI 1.102–1.631) at
Mann–Whitney test (Fig. 2). The presence of four lesions optic nerve abnormalities extension and visual outcome
as a threshold has a sensitivity of 87.5% and a specificity (p = 0.2).
of 66.6% for the diagnosis of MS with area under the curve We observed a significant correlation between orbits
(AUC) of 0.8 (Fig. 3). MRI pattern and RNFL at Kruskal–Wallis test (p = 0.037).
No statistically significant correlation was found between No statistically significant correlation was observed
brain MRI pattern and visual acuity (p = 0.6), neither between orbits MRI pattern and final diagnosis (p = 0.6).
between orbital MRI pattern and visual acuity (p = 0.4). No
statistically significant correlation was found between brain
MRI pattern and visual outcome (p = 0.2), neither between
orbital MRI pattern and visual outcome (p = 0.9).
At Kruskal–Wallis test, no statistically significant cor-
relation was observed between optic nerve abnormali-
ties extension and visual acuity (p = 0.8), nor between

Fig. 1  The box plot shows the extent of signal alterations and was Fig. 3  ROC curve shows the correlation between the lesions number
greater in the optic nerves that demonstrated contrast enhancement and the diagnosis of MS

13

Discussion
Different disorders determine the inflammation of the optic
nerve, but the form caused by MS related demyelination is
the most common [2]. Demyelinating ON represents the
first manifestation of MS in about 20% of patients [19] and
a diagnosis that brings great concerns to patients who are
often young and previously healthy.
The execution of MRI, soon after the onset of symp-
toms, has important implications: first, MRI helps clini-
cians to confirm the diagnosis of ON, but it can also pro-
vide with useful information for patient management and
treatment planning.
In our case series, most optic nerve lesions were in the
intra-orbital segment, and this is in line with the evidence
of another study by Soelberg et al. [4], but our frequency
of optic nerve abnormalities was lower: 65.8% versus
80.6%. Berg et  al. [10], in their study on 104 patients
observed T2 lesions of the optic nerve in 79.8% of patients
and gadolinium enhancement in 74% of patients. In a study
on 37 adult patients with a recent or past attack of ON
who executed obits MRI with STIR sequence [20], high-
signal abnormalities of the optic nerves were found in
84% of symptomatic subjects and poor visual outcome
was observed in patients with more extensive lesions, or
with lesions located in the optic canal. Our study shows
that visual evoked potentials were more sensitive than
MRI in detecting lesions and in diagnosing demyelinat-
ing disease of the optic nerve; however, we must consider
that this study was conducted in 1998 and the MR equip-
ment was certainly less efficient than the currently avail-
able scanners.
STIR sequence showed abnormalities in 88% of acute
ON in another retrospective study [21].
We observed a lower rate of optic nerves altered sig-
nal; however, differences in rates of MRI abnormalities
detected at optic nerves can be explained by different tim-
ings of MRI execution after symptoms onset and by the
beginning of the steroid treatment in our patients: Berg
et al., for example, performed the MRI within 24 h form
the patient’s arrival, before the corticosteroid therapy.
In accordance with the literature, in our group of
patients, all optic nerve abnormalities were in the IO or
CA segment without any involvement of the CH portion,
which is instead considered typical for neuromyelitis
optica spectrum disorder [22, 23].
In our study, we did not demonstrate a significant cor-
relation between orbits MRI pattern and visual outcome
at follow-up.
In a prospective study by Hickman et  al. [6] in 33
patients, 15 of whom performed serial gadolinium-
enhanced orbits MRI until enhancement ceased, short
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acute lesion on triple-dose gadolinium-enhanced imag-
ing are associated with initial improvement in vision
(p < 0.01), but recovery was not related to the duration of
enhancement. Due to the growing evidence of gadolinium
deposition in the brain, especially in patients with ON
(who are usually young and will have to undergo multiple
MRIs during their lifetime in case of diagnosis of MS),
these results are difficult to compare.
Kupersmith et al. [24] analyzed a group of 107 patients
and observed that optic nerves with gadolinium enhance-
ment in the optic canal had poorer color vision, compared
with optic nerves with abnormalities in other segments.
They also report that that when there was complete involve-
ment of all segments of the nerves the threshold perimetry
and color vision were mostly impaired, and that optic nerves
with enhancing segments longer than 17 mm had poorer
baseline visual acuity, threshold perimetry and color vision.
However, visual recovery was similar regardless of location
or length of abnormal enhancement at baseline, and this fact
is in line with our results.
The extension of optic nerve abnormalities has been
proposed as predictor of visual outcome in a study on 22
patients [25], where complete visual recovery was observed
in patients with lesions extension less than 17.5  mm,
whereas lesions greater than 17.5 mm and/or lesions with
intracanalicular location were associated with incomplete
or partial recovery.
The intracanalicular location was identified as a risk
factor for poor outcome also in a retrospective study of
50 patients acute ON, who executed MRI including STIR
sequence of the optic nerve [21], together with initial low
visual acuity (less than 2/10) and the absence of orbital pain.
In the attempt to predict visual recovery after ON, Zhang
et al. [26] proposed the use of texture analysis in a study on
25 patients with acute optic neuritis: open source software
ImageJ was applied for the assessment of texture heterogene-
ity calculated on the coronal STIR image showing the largest
cross-sectional area of the lesion in the optic nerve. They
observed that only baseline lesion texture independently cor-
related with visual recovery at 6 and 12 months, whereas no
other MRI variables at baseline, as altered signal length and
gadolinium enhancement length, nor ophthalmic variables,
as RNFL, correlated with visual outcome. The absence of a
correlation between signal abnormalities in STIR and gado-
linium enhancement of the optic nerves and visual recovery
is in line with our results.
We confirmed that MRI brain lesions at presentation with
optic neuritis (ON) increase the risk of developing clinically
definite multiple sclerosis. The evidence that the presence of
brain lesions at the onset of ON is related to the diagnosis
of MS is in accordance with the literature: previous studies
have reported that patients with no brain lesions at the onset
of ON have a 15–22% risk of MS compared to a 56–88% risk
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in patients with one or more brain lesions [14, 27, 28]. This
evidence has important clinical implications, since these
patients may be later at a greater risk of disability [4].
All patients with spinal lesions received a diagnosis of
MS, and this agrees with other studies [4, 29].
Another option for the assessment of patients affected by
ON is represented by OCT. Data in the literature demon-
strated the relationships between RNFL thickness and visual
acuity, visual field and color vision, and previous results
affirmed that OCT can be used as a noninvasive biomarker
of neurodegeneration and axonal loss in MS [30] and of
optic nerve atrophy [31, 32]. Moreover, a strong correla-
tion between RNFL thickness and visual outcome has been
observed in MS patients [33–35], suggesting that a lower
RNFL thinning in early MS is related to a better visual out-
come [33].We use this ophthalmological technique in com-
bination with MRI examination.
Limitations
Our study has some limitations, first of all the 1-year clini-
cal follow-up: it is indeed possible for the patient to develop
MS at a greater distance of time; however, the same follow-
up period was also considered in other studies in patients
with ON [4, 8, 20, 24]. A longer follow-up is needed to
strengthen our results. This is a retrospective study; how-
ever, we considered only the patients with complete clinical,
ophthalmological and imaging documentation, eliminating
from our case series all patients with partial or incomplete
data; the patient population is not huge, but comparable to
that proposed in other similar studies. Another limitation
is the execution of MRI after the beginning of the steroid
treatment, since the administration of steroids reduces active
lesions contrast enhancement of the optic nerves, brain and
spinal cord.
Conclusions
In conclusion, the correlation between orbits MRI pattern
at baseline and visual recovery remains unclear, whereas
the observation of brain lesions and their number at the first
episode of ON can help predict the development of MS. The
identification of those patients who may convert to MS is
important, as they may later be at greater risk of disability
[30].
Compliance with ethical standards  org/10.1016/j.msard​.2018.02.010
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical standards  As stated in Materials and Methods, this retrospec-
tive study has been approved by our Institutional Review Board (Insti-
tutional Review Board Area 1 Milan; reference number: 2018/ST/116).
All procedures performed in studies involving human participants were
in accordance with the ethical standards of the institutional and national
research committee and with the 1964 Helsinki Declaration and its
later amendments.
Informed consent  Informed consent was obtained from all individual
participants included in the study.
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