Hot Seat #80: 18 yo F with acute vision loss
Posted on: September 12, 2016, by : Jeremy Root
Jeremy Root, Children’s National Medical Center
with Asha Payne, Children’s National Medical Center
The Case
18 year-old previously healthy female presents to the ED with vision loss in her right eye. The patient says she developed visual changes in the superior aspect of her right eye two hours prior to presentation. She describes complete loss of vision in the right superior nasal visual field and blurry vision in the right superior temporal field. She noticed the visual changes when she was looking at her phone two hours prior to presentation. Denies any precipitating events. Symptoms have been consistent for past two hours. Patient reports history of migraines, last one occurred 6 months ago. She presents to the ED today due to her acute vision changes.
ROS: Denies headache, eye pain, ocular discharge, photophobia, fevers. Denies recent trauma.
PMH: Hx of migraines, No current medications, specifically no birth control
PE:
VS T 36.9, HR 76, RR 16, BP 113/72, SpO2 100%, Wt 55kg
GEN: Well-appearing, active, smiling, no distress
CV/PULM: CTAB, heart RR, no murmurs or gallops
ABD: soft, NT, no HSM
EYE: PERRL, EOMI, normal conjunctiva, no discharge, L eye 20/50, R eye 20/40, decreased visual field in R superior nasal quadrant
NEURO: CN II-XII intact, normal sensory, normal motor, normal speech, normal strength
Question 1:
You consult neurology who feels presentation is most consistent with ocular rather than neurologic/CNS etiology. They do not feel monocular vision loss is consistent with a stroke and do not feel CNS imaging is necessary. Your patient’s symptoms are unchanged.
Question 2:
You decide not to perform any further workup in the ED.
Question 3:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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I would hope that someone attempted a good fundoscopic examination in the ED before calling Ophthalmology, looking specifically for optic neuritis which can be associated with Devic’s/NMO and multiple sclerosis. Also, it would be good to assess for loss of color vision in the right eye, which might be an early sign of worsening vision loss. If indeed optic neuritis is confirmed, then this patient will need pulse corticosteroids — which would require admission rather than d/c to outpatient f/u.
I agree- I think more of an exam would be essential before involving any consultants. Remember if you have a patient who is having difficulty cooperating with fundoscopy or you can’t see everything you want to, bedside ocular ultrasound is an exceedingly easy way to look for retinal detachment, vitreous hemorrhage, and can even give you clues about increased ICP by measuring the optic nerve diameter. With the relatively acute onset, this would be one I would insist an ophtho resident come see, and if in the community without residents on call, at least first thing in am ophtho.
I agree with everything mentioned above. This would also be a good case in which contacting the PMD would be critical (hopefully she has one with whom the family has a good relationship). I’d also make sure to press Optho to make sure the follow-up plan makes sense for whatever the working differential is and make sure to review it with the family before discharge.
Right now retinal detachment, optic neuritis, and retinal artery occlusion (given no acute trauma) are my biggest concerns here. All of which would require an urgent ophthalmology consult in the ED. Depending on their findings, she would need to proceed to MRI to rule out MS (as Dewesh noted), MRA/MRV/a good to rule out retinal vessel occlusion. All would require urgent admission and intervention. Given the sudden onset of symptoms, these should all be in the differential. This patient’s vision deficits, however, are not as profound as seen with retinal stroke (this patient has bilateral acuity deficits with right superior field loss.
One of the more benign diagnoses here would be an atypical migraine in an adolescent female. Even without concurrent headache, this can be a presentation of migraine. As long as she has no bleeding issues/retinal detachment issues, I may try her on the migraine pathway.