3/23/2017 0 Comments Case study: a medical conundrumA 60 year old female was referred for a cataract evaluation. She presented with a three-month history of progressive difficulty driving at night due to glare. An examination demonstrated BCVA of 20/20 OD and 20/30 OS with Brightness Acuity Testing of 20/25 OD and 20/80 OS. Her remaining examination was unremarkable with the exception of 1+ NS OD and 2+ NS OS as well as trace epiretinal membrane in the left macula. The patient subsequently underwent an uncomplicated cataract extraction in the left eye. At one week post op, she demonstrated a BCVA of 20/50 with clear cornea, quiet anterior chamber and well centered PCIOL. At one month, BCVA had dropped to 20/80 while her anterior segment continued to remain clear. Sir Isaac Newton's third law of motion states that (paraphrased from the original), "For every action, there is an equal and opposite reaction." No, we aren't going to give you a physics lecture. But this makes sense, right? Especially in the medical world. When a patient comes into your office and describes their vision as "foggy" and tells you they often have blurred vision and difficulty driving at night, it is reasonable to include cataracts in your list of differential diagnoses. Once it is diagnosed and removed (the action), it is expected that the patient's vision and quality of life will improve dramatically (the reaction). When the reaction isn't what we expect, it turns into a bit of a medical conundrum. Not What We Expected A 60 year old female was referred for a cataract evaluation. She presented with a three-month history of progressive difficulty driving at night due to glare. An examination demonstrated BCVA of 20/20 OD and 20/30 OS with Brightness Acuity Testing of 20/25 OD and 20/80 OS. Her remaining examination was unremarkable with the exception of 1+ NS OD and 2+ NS OS as well as trace epiretinal membrane in the left macula. The patient subsequently underwent an uncomplicated cataract extraction in the left eye. At one week post op, she demonstrated a BCVA of 20/50 with clear cornea, quiet anterior chamber and well centered PCIOL. At one month, BCVA had dropped to 20/80 while her anterior segment continued to remain clear. At this point, you might start to wonder about the possibility of macular edema. Macular OCT Scan An Optic Nerve Head scan was obtained at the time of her macular OCT. There was, however, mild RNFL thinning temporally on the nerve scans (OS>OD). At that time, a neuro-ophthalmology consult was scheduled with Dr. Kristin Madonia of VisionAmerica. One week later when she presents for this appointment, visual acuity in the left eye measured 20/200. The remaining neuro exam was normal except for trace temporal pallor of the left optic nerve. Visual field test were performed. VF Results During this appointment, an MRI of the brain and orbits were obtained. MRI Results As seen in the MRI image above, the patient was found to have a large meningioma arising from the left lesser wing of the sphenoid with associated vascular encasement and mass effect. The patient was subsequently scheduled for neurosurgical consultation and eventually had surgery. Meningiomas As a reminder, and as it sounds, meningiomas originate from the meninges surrounding the brain and spinal cord. Although most meningiomas are encapsulated and benign tumors, their intracranial location often leads to serious and potentially lethal consequences. They are the most frequently diagnosed primary brain tumor accounting for 33.8% of all primary brain and central nervous system tumors reported in the United States between 2002 and 2006. 1 Most meningiomas are slow growing and treatment depends on the location and symptoms. While many can simply be observed, others will require surgery and radiation. 2
A case like this can be challenging and is a good reminder that things aren't always as they seem. It occasionally takes additional tests to discover something that isn't on your radar. Do you have a similar story to share? We would love to hear it and potentially share it with our readers. Reply to this email and let us know!
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