In this short video interview, Gregor Brecl Jakob discusses the critical need for caution when attributing optic nerve pathology to multiple sclerosis. While optic nerve involvement is acknowledged in the diagnostic criteria, he emphasizes that optic neuritis has a broad differential diagnosis and should never be assumed to be MS-related without careful evaluation.
Watch the interview
Why is careful differential diagnosis essential when assessing optic nerve pathology in suspected multiple sclerosis?
Gregor Brecl Jakob explains how specific clinical, imaging, and ophthalmological features can help distinguish MS-related optic neuritis from other inflammatory or non-inflammatory optic neuropathies.
Key points discussed include:
- Optic nerve involvement is mentioned in MS diagnostic criteria, but requires cautious interpretation
- Optic neuritis has a wide differential diagnosis beyond MS
- MOGAD commonly presents with bilateral optic nerve lesions and severe visual impairment
- Aquaporin-4–positive disease may involve the optic tract and chiasm on MRI
- MRI findings extending beyond the optic nerve raise suspicion for alternative diagnoses
- Retinal features such as perineuritis, papilledema, and hemorrhages are important red flags
- Poor visual recovery after relapse suggests non-MS etiologies
- Other causes, including compressive optic neuropathies, must be excluded
- Optic nerve pathology should only be attributed to MS after thorough exclusion of mimics
Throughout the interview, the emphasis is on diagnostic precision—ensuring that optic nerve pathology is correctly classified to guide appropriate management and avoid potentially harmful misdiagnosis.
Are there any particular clinical or imaging red flags you believe clinicians should be aware of?
* Please note that all the captions were generated automatically. If they do not appear, click on CC in the navigation.
Key messages from Gregor Brecl Jakob
Optic nerve pathology alone is not sufficient to diagnose multiple sclerosis. In the interview, Gregor Brecl Jakob stresses that a structured and cautious diagnostic approach is essential, given the wide range of inflammatory and non-inflammatory conditions that can affect the optic nerve.
By carefully evaluating clinical presentation, MRI patterns, retinal findings, and recovery profile and by actively excluding key mimics such as MOGAD and aquaporin-4–positive disease clinicians can improve diagnostic accuracy and ensure patients receive the most appropriate treatment. Overall, the interview advocates for a careful, differential-driven approach to optic neuritis within modern MS diagnostics.
Curious to learn more about the expert behind this interview?
Assist. Prof. Gregor Brecl Jakob, MD, PhD, is Head of the Centre for Multiple Sclerosis at
the Department of Neurology, University Medical Centre Ljubljana, Slovenia. He is a
neurology consultant with a strong academic and clinical focus on multiple sclerosis and
neuroimmunology. Dr. Brecl Jakob completed his PhD at the University of Ljubljana, where
his research explored the impact of cognitive load on balance and gait in patients with
clinically isolated syndrome.
He is an active member of the European Academy of Neurology and serves on the ECTRIMS
Council (2020–2024). In addition to his clinical roles, he is a principal investigator in
international clinical trials and a published author in numerous peer-reviewed journals on MS
diagnostics, treatment, and patient outcomes.
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