Clinical examination of eye movements, with attention to dynamic properties of saccades and the vestibulo-ocular reflex, takes only a few minutes to perform, but may provide better information concerning the presence of brainstem and cerebellar involvement than Kurtzke protocols. Measurement of SVV is possible in the clinic and is a sensitive sign of brainstem dysfunction; our present study suggests that SVV is also affected when cerebellar circuits are involved in MS. Prospective studies are required to determine whether the development of abnormalities with ocular motor and SVV testing are predictive of disease activity and progressive disability in MS.

We conducted a two-year follow-up study of 40 patients with MS in whom we had reported that abnormal eye movements (AEM) were associated with greater general disability. AEM patients (17/40) remained significantly (p < .001) more disabled (median EDSS of 7.0) than those with normal eye movements (median EDSS of 5.0). AEM and great disability were associated with abnormal MRI signals in brainstem or cerebellum, where disease may involve control circuits for eye movements as well as descending motor pathways.

The treatment era for multiple sclerosis began in 1993 with the approval of the first disease-modifying therapy. This changed the management of multiple sclerosis from treating acute exacerbations to focusing on preventive therapeutic options that lessen the risk for exacerbations, changes on magnetic resonance imaging, and disability as measured by the Expanded Disability Status Scale. Currently, there are 8 therapies approved to treat multiple sclerosis: beta-interferons (Avonex, Betaseron, Extavia, and Rebif), fingolimod (Gilenya), glatiramer acetate (Copaxone), mitoxantrone (Novantrone), and natalizumab (Tysabri). These agents will be reviewed including the pivotal trial data, mechanisms of action, and side effects. The timing of beginning therapy and selection of these agents must be individualized for each patient depending upon patient preference, tolerability, clinical and magnetic resonance imaging disease activity, and disease course. All of the current treatments are approved for relapsing disease. To date only the injectable agents, including interferons and glatiramer acetate, have been shown to be of benefit when started after an initial demyelinating event referred to as clinically isolated syndrome. Mitoxantrone was approved for progressive relapsing and secondary progressive multiple sclerosis, although its use is limited by potential risks such as cardiotoxicity and leukemia. Although these agents have made a significant impact on the treatment of multiple sclerosis, they are often only partially effective, so patients may continue to have disease activity. Multiple new agents are currently being tested in clinical trials and it is likely our treatment paradigms will change as more effective therapies become available.

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