The use of optical coherence tomography and visual evoked potentials in the 2024 McDonald diagnostic criteria for multiple sclerosis

Shiv Saidha; Ari J Green; Letizia Leocani; Angela Vidal-Jordana; Rachel C Kenney; Gabriel Bsteh; Olivier Outteryck; Alan Thompson; Xavier Montalban; Timothy Coetzee; Axel Petzold; Friedemann Paul; Laura J Balcer; Peter A Calabresi

doi:10.1016/S1474-4422(25)00275-3

The use of optical coherence tomography and visual evoked potentials in the 2024 McDonald diagnostic criteria for multiple sclerosis

Lancet Neurol. 2025 Oct;24(10):880-892. doi: 10.1016/S1474-4422(25)00275-3.

Authors

Affiliations

¹ Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: ssaidha2@jhmi.edu.
² Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA; Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.
³ Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy.
⁴ Multiple Sclerosis Centre of Catalonia, Autonomous University of Barcelona, Barcelona, Spain.
⁵ Department of Neurology, New York University School of Medicine, New York, NY, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA.
⁶ Department of Neurology, Medical University of Vienna, Vienna, Austria; Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria.
⁷ Department of Neuroradiology, U1172 Lil'NCOg, University of Lille, Lille, France.
⁸ Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.
⁹ Multiple Sclerosis Centre of Catalonia, Autonomous University of Barcelona, Barcelona, Spain; Department of Neurology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain; Universitat de Vic-Central de Catalunya, Vic, Spain.
¹⁰ National Multiple Sclerosis Society, New York, NY, USA.
¹¹ Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK; Department of Neuro-ophthalmology, National Hospital for Neurology and Neurosurgery and Moorfields Eye Hospital, London, UK.
¹² NeuroCure Clinical Research Center, Charité, Department of Neurology, Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, and Charité Universitätsmedizin Berlin, Berlin, Germany.
¹³ Department of Neurology, New York University School of Medicine, New York, NY, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Ophthalmology, New York University School of Medicine, New York, NY, USA.
¹⁴ Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Wilmer Eye Institute, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Solomon Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: pcalabr1@jhmi.edu.

PMID: 40975103
DOI: 10.1016/S1474-4422(25)00275-3

Abstract

The 2024 revisions of the McDonald diagnostic criteria include the optic nerve as a fifth anatomical location within the CNS for the diagnosis of multiple sclerosis, in addition to periventricular, juxtacortical or cortical, infratentorial, and spinal cord lesions. Demonstration of dissemination in space can now be achieved with the detection of typical lesions in at least two of these five locations. We review the evidence supporting the use of optical coherence tomography (OCT) and visual evoked potentials (VEPs) to show optic nerve involvement in the diagnosis of multiple sclerosis. We also report consensus recommendations for their use. Provided there is no better explanation for optic nerve involvement and that rigorous quality control is applied, OCT-derived peripapillary retinal nerve fibre layer inter-eye differences of 6 μm or greater or composite macular ganglion cell and inner plexiform layer inter-eye differences of 4 μm or greater support optic nerve injury. Delayed VEP latency, which depends on technical and methodological factors, and is centre and device dependent, supports demyelinating optic nerve injury when done with appropriate technical knowledge and interpretation.

Publication types

Review

MeSH terms

Evoked Potentials, Visual* / physiology
Humans
Multiple Sclerosis* / diagnosis
Multiple Sclerosis* / diagnostic imaging
Multiple Sclerosis* / physiopathology
Optic Nerve* / diagnostic imaging
Optic Nerve* / pathology
Optic Nerve* / physiopathology
Tomography, Optical Coherence* / methods
Tomography, Optical Coherence* / standards