Oftentimes, the patients that end up in your office are not the ones you would expect. They are young and seem to be doing everything they can to stay healthy. Nevertheless, something happens and they end up in our exam rooms. The challenge here is that, with a seemingly healthy patient, a diagnosis can seem more like a wild goose chase than an educated approach. You find yourself saying, "Well, it's not that. It might be this." Then it's on to the next test. The case report we are sharing today is similar. The diagnosis was challenging and it took multiple tests for us to discover what was causing the symptoms. Thankfully, we were able to find the answer and treat the patient. Dr. Trenton Cleghern is the author of this piece. He titled it, "Old Mystery Solved." A 39-year-old female presented with complaints of blurry vision and eye pain in the left eye after jogging that morning. She reported that she had experienced approximately three episodes of visual disturbances. The patient reported seeing sparkling lights and also missing numbers on a clock. This is a combination of positive and negative visual phenomenon. She also experienced eye pain that was described as "a pressure behind the eye" and had a headache on the left side. Her symptoms sounded like pigment dispersion syndrome, as exercise can liberate pigment from the posterior iris into the anterior chamber angle leading to a rise in intraocular pressure. This spike in pressure may lead to blurred vision and if elevated enough, eye pain. The other condition to consider when exercise leads to blurred vision and/or eye pain is optic neuritis. When body temperature is elevated and causes optic neuritis symptoms in multiple sclerosis patients, it is referred toas Uhthoff's phenomenon. This young lady had been a patient in our retina clinic a few years ago. At that time, she had a central retinal vein occlusion in her right eye. As this is extremely rare in a young healthy person, an extensive laboratory investigation was initiated. However, all testing was unremarkable at that time. During her first visit, the patient denied taking any medication, including birth control. Her visual acuity was quite poor in that eye, so as one could imagine it was disconcerting to have vision changes in her "good" eye. By the time she arrived at our office, her visual symptoms had resolved and her headache was subsiding. Her medical history was unremarkable and she was still not taking any prescribed medications. Preliminary testing: VA OD: CF @ 3' PHNI OS: 20/20 Pupils OD: 2+APD OS: reactive to light EOM Full range of motion OU The patient's anterior segment was unremarkable in both eyes; no signs of pigment dispersion were observed in either eye. A gonioscopy was also performed and the trabecular meshwork did not have increased pigmentation. The posterior segment in the right eye revealed signs of an old retinal vein occlusion, including a mottled macular appearance and optic nerve pallor. The posterior segment of the left eye was unremarkable. A macula and optic nerve OCT of the left eye was obtained and both were within normal limits. A full threshold Humphrey visual field was obtained on the left eye. Due to the reduced acuity, the OCT and visual field were not able to be performed on the right eye. The visual field was unreliable due to fixation losses, but there was a faint central scotoma. At this point, there were a few differential diagnoses to consider: migraine, optic neuritis, or a vascular insufficiency. The original differential of pigment dispersion was eliminated since there were no signs in either eye. Since she had never experienced a migraine in the past, was functional monocular, and optic neuritis was a potential diagnosis, an imaging study was ordered. An MRI of the brain and orbits, with and without contrast, was ordered as so on as possible. The MRI of the orbits was unremarkable and showed no signs of optic neuritis. The MRI of the brain revealed a focal, wedge-shaped subacute infarction in the frontoparietal region. Here is a photo similar to this case. This is a post-IV contrast MRI of a patient with a sub-acute infarction of the left posterior frontal lobe. This indicated she had experienced a sub-acute stroke. The patient was immediately contacted and instructed to go to the emergency room for a sub-acute stroke evaluation. She was hospitalized for three days and diagnosed with protein C/S deficiency. The patient was discharged after the three days and prescribed rivaroxaban, which is a blood thinner that also goes by the trade name Xarelto. Protein C or S deficiency is a blood clotting disorder that can lead to increased clotting and thrombosis. This is what led to the stroke and, most likely, the etiology of the central retinal vein occlusion three years prior. When young patients present with conditions caused by presumed vascular disease, a coagulopathy should be considered. Finally, with neuro-ophthalmic disease, it is always better to be quick to pull the trigger in ordering neurological imaging. This can help uncover a diagnosis, and, in some cases, save a patient's life. By: Trenton Cleghern, OD, FAAO VisionAmerica
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AuthorThe staff and doctors at VisionAmerica are committed to providing relevant information for you, your patients and your practice. We hope you find the information in our blog post helpful. Archives
August 2019
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