Optic nerve pathologies in multiple sclerosis based on the new McDonald criteria 2024

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS) characterized by demyelination, gliosis, and neurodegeneration. One of the most frequent and often initial manifestations of MS is optic neuritis (ON), occurring in about 25% of patients as the first symptom and in up to 50% during the disease course. The 2024 revision of the McDonald criteria introduced a major change by including the optic nerve as the fifth anatomical location demonstrating dissemination in space (DIS), thereby enhancing the diagnostic sensitivity of MS. Optic nerve involvement can now be confirmed through structural (magnetic resonance imaging [MRI], optical coherence tomography [OCT]) and functional tests (visual evoked potentials [VEP]), which allow detection of both clinical and subclinical demyelinating lesions. The diagnostic and classification framework proposed by Petzold et al. (2022) integrates clinical presentation, paraclinical evidence, and serological biomarkers, improving differentiation between autoimmune etiologies such as MS, neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). The recognition of ON as an independent diagnostic region in the 2024 McDonald criteria represents a significant step forward in early MS diagnosis and in the initiation of disease-modifying therapies, ultimately improving long-term prognosis and patients' quality of life.