I Googled Eye Puns But Couldn’t Find Any That Weren’t Cornea

Written by: Dr. Rebecca Zhang

Edited by: Dr. Joann Hsu

The case:

26 year old male with no PMHx presents to ED for sudden onset left-sided vision loss x 2 days after waking up. Patient states that his head has been hurting but denies other symptoms such as eye pain. He woke up that morning feeling like his left eye became very blurry. Reports his right eye has been fine. No fever, chills, headache, dizziness, nausea, or vomiting. 

The exam:

Patient is awake, alert, and in no acute distress. 

SKIN: Warm, dry; (-) cyanosis; (-) rash.

HEAD: (-) scalp swelling, (-) tenderness.

EYES: (-) conjunctival pallor, (-) scleral icterus, (+) visual acuity is 20/20 OD and unable to assess OS as patient cannot visualize Snellen's, (+) right-ward deviation of the left eye with concentration, (+) left eye minimally more dilated than the right but both reactive to light, (+) IOP OD 23.6 and OS 22.6, 

The bedside ultrasound:

Papilledema 

Definition: Optic disc swelling due to increased ICP

Common Causes:

  • Malignant Hypertension

  • Idiopathic Intracranial HTN

  • Intracranial Mass

  • Hydrocephalus

Clinical Features

  • Headache worse in the morning

  • Nausea, vomiting

Back to the case:

Ophthalmology was consulted and note a prominent afferent pupillary defect of the left eye on their exam

Combined with grade 4 optic disc edema, this is concerning for…


Optic Neuritis

Background/etiology

  • Inflammatory or demyelinating disease, associated with MS in young, female, caucasian patients

  • Idiopathic

  • Multiple sclerosis

  • Viral infections

Clinical features/Exam

  • Acute monocular vision loss occurring over days but usually within hours with retro-orbital headache and pain

  • Afferent Pupillary Defect

  • Normal IOP with papilledema on ultrasound

Disposition

  • Admit

  • Inpatient neurology workup and management

  • IV Solumedrol 1g QD x 3 days

Timeline of the case

Day 1: Presented to ED

Day 2: Quantiferon gold returns positive for latent TB, MRI orbits confirmed optic neuritis, CTA head neck, MRI brain normal, no stroke

Day 5: Discharged, visual acuity back to baseline!

Happy scanning!

Resources:

Voss E et al. Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis. Ther Adv Neurol Disord. 2011 Mar; 4(2): 123–134.

Shevlin C. Optic Nerve Sheath Ultrasound for the Bedside Diagnosis of Intracranial Hypertension: Pitfalls and Potential. http://www.criticalcarehorizons.com/optic-nerve-sheath-diameter-icp/


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