Sudden onset blurred vision with visual floaters in a 51-year-old man

Purpose: We report a case of multiple sclerosis with bilateral optic neuritis that was atypical in terms of both the clinical signs and symptoms.Case summary: A 34-year-old female visited the department of neurology with a complaint of sudden-onset, left lower extremity weakness and numbness that had developed 3 weeks prior, and bilateral blurred vision that had commenced 2 weeks prior. The patient was diagnosed with multiple sclerosis and prescribed high-dose intravenous methylprednisolone for 3 days, but the blurred vision did not improve. The patient was referred to the ophthalmology department. The initial best-corrected visual acuity was 0.04 in both eyes, and the relative afferent pupillary defect test was positive for the left eye. The Ishihara color test scores were 1/17 for both eyes. No optic disc swelling was evident on fundus examination. Brain and spine magnetic resonance imaging (T2-weighted) performed during the initial visit revealed lesions of high signal intensity in the frontal, subcortical white matter; the optic chiasm; the left retrobulbar optic segment; the medulla; and the spinal C2-5 processes. Aquaproin-4 immunogloblin G antibody (AQP4-IgG Ab) was not detected in serum. One month after prescription of the oral steroid, the vision improved to 1.0 in the right and 0.8 in the left eye. The patient was lost to follow-up after prescription of interferon-beta for 4 years, without recurrence.Conclusions: Binocular optic neuritis accompanied by severe visual loss is a rare form of multiple sclerosis. A thorough diagnosis (with a focus on exclusion) is required, as is appropriate treatment.

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Adenosine-Induced Cardiac Arrest for Transvenous Embolization of Midbrain Arteriovenous Malformation

Operative Neurosurgery ◽

10.1093/ons/opz330 ◽

2019 ◽

Vol 18 (6) ◽

pp. E184-E190 ◽

Cited By ~ 1

Author(s):

Jaims Lim ◽

Hussain Shallwani ◽

Kunal Vakharia ◽

Adnan H Siddiqui

Keyword(s):

Arteriovenous Malformation ◽

Transarterial Embolization ◽

Posterior Wall ◽

Sudden Onset ◽

High Flow ◽

Neurological Deficits ◽

Transvenous Embolization ◽

Blurred Vision ◽

Systemic Hypotension ◽

The Right

Abstract BACKGROUND AND IMPORTANCE Few studies describe the use of adenosine-induced cardiac systole for treatment of cerebrovascular pathologies. We describe a midbrain arteriovenous malformation (AVM) treated with transvenous embolization using adenosine-induced asystole to achieve transient systemic hypotension with the purpose of furthering discussion on the technique and operative considerations for adenosine use in endovascular AVM treatments. CLINICAL PRESENTATION A 29-yr-old man presented with sudden onset of severe bilateral headache, blurred vision, and numbness on the right side of his face and tongue. Noncontrast head computed tomography revealed fourth ventricle hemorrhage. Diagnostic cerebral angiography revealed a high-flow midbrain AVM with a posterior wall perforator from the basilar artery terminus and a draining vein into the straight sinus. Transarterial AVM embolization was successful. The patient was discharged with no residual neurological deficits but returned 1 wk later with slurred speech and left-sided dysmetria. Repeat angiography revealed partial AVM filling. Attempts at transarterial embolization were unsuccessful. Thus, transvenous AVM embolization with adenosine-induced cardiac asystole and systemic hypotension was performed. A total of 60 mg of adenosine was administered, followed by 2 additional doses of 60 and 40 mg; and complete cardiac asystole with a mean arterial pressure of 40 mmHg was maintained, resulting in successful embolization of the AVM. No residual filling was visualized on postembolization arterial angiography runs. The patient was neurologically stable and discharged on postoperative day 2. CONCLUSION With appropriate and safe dosing, adenosine-induced asystole and systemic hypotension may be a feasible, safe option to reduce flow and assist endovascular transvenous embolization of high-flow AVMs.

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Uveitis in spondyloarthritis

Therapeutic Advances in Musculoskeletal Disease ◽

10.1177/1759720x20951733 ◽

2020 ◽

Vol 12 ◽

pp. 1759720X2095173

Author(s):

Judith Rademacher ◽

Denis Poddubnyy ◽

Uwe Pleyer

Keyword(s):

Effective Treatment ◽

Biological Treatment ◽

Diagnostic Delay ◽

Sudden Onset ◽

Topical Steroids ◽

Close Collaboration ◽

Blurred Vision ◽

Ocular Symptoms ◽

Referral Strategy ◽

Necrosis Factor

Uveitis is the most frequent extra-articular manifestation of axial spondyloarthritis (SpA), occurring in up to one-third of the patients. In the majority of patients, uveitis is acute, anterior and unilateral and presents with photosensitivity, sudden onset of pain and blurred vision. Topical steroids are an effective treatment; however, recurrent or refractory cases may need conventional disease-modifying antirheumatic drugs or biological treatment with monoclonal tumor necrosis factor (TNF) inhibitors, thus also influencing treatment strategy of the underlying SpA. Though the exact pathogenesis of SpA and uveitis remains unknown, both seem to result from the interaction of a specific, mostly shared genetical background (among other HLA-B27 positivity), external influences such as microbiome, bacterial infection or mechanical stress and activation of the immune system resulting in inflammation. Up to 40% of patients presenting with acute anterior uveitis (AAU) have an undiagnosed SpA. Therefore, an effective referral strategy for AAU patients is needed to shorten the diagnostic delay of SpA and enable an early effective treatment. Further, the risk for ophthalmological manifestations increases with the disease duration in SpA; and patients presenting with ocular symptoms should be referred to an ophthalmologist. Thus, a close collaboration between patient, rheumatologist and ophthalmologist is needed to optimally manage ocular inflammation in SpA.

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A Case of Idiopathic Dense Vitreous Hemorrhage: Suspected Rupture of a Large Retinal Arterial Macroaneurysm on the Optic Disc

Case Reports in Ophthalmology ◽

10.1159/000511110 ◽

2021 ◽

pp. 634-639

Author(s):

Shizuka Takahashi ◽

Kentaro Nishida ◽

Hirokazu Sakaguchi ◽

Kohji Nishida

Keyword(s):

Macular Hole ◽

Optic Disc ◽

Vitreous Hemorrhage ◽

Unknown Origin ◽

Internal Limiting Membrane ◽

Sudden Onset ◽

Acute Onset ◽

Blurred Vision ◽

Disc Diameter ◽

Retinal Arterial Macroaneurysm

We report a novel case of vitreous hemorrhage associated with suspected rupture of 2-disc-diameter retinal arterial macroaneurysm on the optic disc. A 90-year-old woman presented with blurred vision (sudden onset) in her left eye. Examination of the fundus revealed acute onset vitreous hemorrhage of unknown origin without retinal detachment. She underwent vitrectomy, but after excision of the dense vitreous hemorrhage, a 2-disc-diameter hematoma appeared on the optic disc and was removed promptly. Because the bleeding at the base of the hematoma was of arterial origin and pulsating, the first vitrectomy could not achieve hemostasis. Five days after the first surgery, we performed a second vitrectomy. This revealed a subretinal hemorrhage along the superior and inferior arcade vessels and a macular hole, which was almost completely closed with an inverted internal limiting membrane flap. Unfortunately, the macular hole reopened 41 days after the second surgery. In patients presenting with only a large hematoma on the optic disc, it might be prudent to leave the hematoma. However, this large retinal arterial macroaneurysm was on a rare location on the optic disc, making it doubly difficult for the surgeons to diagnose and choose the best option intraoperatively. The differential diagnosis for dense vitreous hemorrhage of unknown origin should include a large retinal arterial macroaneurysm on the optic disc.

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Varicella Zoster Meningitis, Optic Neuritis Preceding the Development of Posterior Outer Retinal Necrosis, and Central Retinal Artery Occlusion in a HIV Patient

Case Reports in Medicine ◽

10.1155/2019/4213162 ◽

2019 ◽

Vol 2019 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Manasa Gunturu ◽

Shiva Kumar Gosi ◽

Swetha Kanduri ◽

Vishnu Garla

Keyword(s):

Optic Neuritis ◽

Central Retinal Artery Occlusion ◽

Retinal Artery Occlusion ◽

Artery Occlusion ◽

Sudden Onset ◽

Blurred Vision ◽

Cerebral Angiogram ◽

Varicella Zoster ◽

Csf Analysis ◽

Retinal Artery

Varicella-zoster virus (VZV) has been known to cause various eye disorders in both immunocompetent and immunocompromised patients. We present a case of a forty-nine-year-old female patient with acquired immunodeficiency syndrome (AIDS) who presented with headache, fever, and blurred vision. Cerebrospinal fluid (CSF) analysis was consistent with VZV meningitis. Magnetic resonance imaging (MRI) of the brain showed enhancement of the right optic nerve indicative of optic neuritis. She responded well to acyclovir and steroids and discharged on the same. Four weeks after discharge, she presented with sudden onset blindness in the left eye. A cerebral angiogram revealed left retinal artery occlusion and was treated with tissue plasminogen activator (tPA). Funduscopic examination showed patchy areas of necrosis in the periphery which were rapidly progressive, diagnostic of posterior outer retinal necrosis (PORN). She was started on ganciclovir and cidofovir and experienced significant improvement in her visual acuity.

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SUDDEN ONSET OF BLURRED VISION IN A THIRTEEN-YEAR-OLD GIRL

The Pediatric Infectious Disease Journal ◽

10.1097/00006454-199511000-00024 ◽

1995 ◽

Vol 14 (11) ◽

pp. 1016 ◽

Cited By ~ 2

Author(s):

MOSES GROSSMAN ◽

PARVIN H. AZIMI ◽

Sylvia M. Delius Maxwell

Keyword(s):

Sudden Onset ◽

Blurred Vision

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Isolated bilateral horizontal gaze palsy as first manifestation of multiple sclerosis

Multiple Sclerosis Journal ◽

10.1177/1352458513518627 ◽

2014 ◽

Vol 20 (6) ◽

pp. 754-755 ◽

Cited By ~ 9

Author(s):

Stefan Kipfer ◽

David W Crook

Keyword(s):

Multiple Sclerosis ◽

Brain Magnetic Resonance Imaging ◽

Sudden Onset ◽

Neurological Deficits ◽

Medial Part ◽

Blurred Vision ◽

Initial Manifestation ◽

Pontine Tegmentum ◽

Horizontal Gaze ◽

Gaze Palsy

Predilection sites for infratentorial multiple sclerosis lesions are well known and frequently involve the fasciculus longitudinalis medialis leading to classical internuclear ophthalmoplegia. We report a very rare oculomotor disorder due to a demyelinating central nervous system (CNS) lesion in the medial part of the lower pontine tegmentum. A 36-year-old man presented with sudden onset of blurred vision. Clinically there was limited eye adduction and abduction to either side, which corresponds to bilateral horizontal gaze palsy. Brain magnetic resonance imaging (MRI) showed a demyelinating CNS lesion affecting the fasciculus longitudinalis medialis, abducens nuclei or abducens fibres in the medial part of the lower pontine tegmentum. Furthermore there were six further demyelinating white matter lesions fulfilling all Barkhof criteria for multiple sclerosis. Demyelinating CNS lesions causing isolated bilateral horizontal gaze palsy are exceptional and usually associated with further focal neurological deficits, which was not the case in the presenting patient. This is a unique video report of isolated bilateral horizontal gaze palsy as the initial manifestation of demyelinating CNS disease, which lead to definite diagnosis of relapsing remitting multiple sclerosis.

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When You “Can’t See” a Case of Relapsing Polychondritis

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/23247096211052175 ◽

2021 ◽

Vol 9 ◽

pp. 232470962110521

Author(s):

David Contreras ◽

Navpreet Dhillon ◽

Rupam Sharma ◽

Varun Bali ◽

Sabetian Katayon ◽

...

Keyword(s):

Immunosuppressive Treatment ◽

Relapsing Polychondritis ◽

Autoimmune Disorder ◽

Sudden Onset ◽

High Dose ◽

Ocular Involvement ◽

Resonance Imaging ◽

Cns Involvement ◽

Blurred Vision ◽

Magnetic Resonance Imaging Mri

Relapsing polychondritis (RP) is a rare and, if not treated, potentially lethal autoimmune disorder. Involvement of central nervous system (CNS) in RP is rare and, when present, makes it extremely difficult to diagnose. In this report, we present a case of a 22-year-old Hispanic woman who presented with sudden onset of headache and blurred vision. Magnetic resonance imaging (MRI) of her brain and orbit showed leptomeningeal enhancements in addition to asymmetrical thickening and enhancement of globes. Her lumbar puncture was consistent with aseptic meningitis picture, and she was placed on empirical treatment for presumptive CNS tuberculosis. Her vision deteriorated, and she was diagnosed with RP with CNS and ocular involvement and placed on high-dose steroids with dramatic rapid response. She has been on immunosuppressive treatment, including Sulfasalazine and Methotrexate, since then and her disease has been under control with decreased need for ophthalmic steroid drops. There have been only 19 previous cases found in literature reporting an association of RP with CNS involvement.

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HTLV-1 uveitis and Graves' disease presenting with sudden onset of blurred vision

The Lancet ◽

10.1016/s0140-6736(21)02442-9 ◽

2022 ◽

Vol 399 (10319) ◽

pp. 60

Author(s):

Koju Kamoi ◽

Kaoru Uchimaru ◽

Arinobu Tojo ◽

Toshiki Watanabe ◽

Kyoko Ohno-Matsui

Keyword(s):

Sudden Onset ◽

Graves Disease ◽

Blurred Vision

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Intramuscular Nerve and Neuromuscular Junction Alteration In Extraocular Muscles of Diabetic Mice

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100120102 ◽

1985 ◽

Vol 43 ◽

pp. 682-683

Author(s):

Bruce R. Pachter

Keyword(s):

Diabetes Mellitus ◽

Peripheral Nerves ◽

Sudden Onset ◽

Extraocular Muscles ◽

Diabetic Patients ◽

Oculomotor Palsy ◽

Third Nerve Palsy ◽

Patients With Diabetes ◽

Intramuscular Nerve ◽

Oculomotor Nerves

Diabetes mellitus is one of the commonest causes of neuropathy. Diabetic neuropathy is a heterogeneous group of neuropathic disorders to which patients with diabetes mellitus are susceptible; more than one kind of neuropathy can frequently occur in the same individual. Abnormalities are also known to occur in nearly every anatomic subdivision of the eye in diabetic patients. Oculomotor palsy appears to be common in diabetes mellitus for their occurrence in isolation to suggest diabetes. Nerves to the external ocular muscles are most commonly affected, particularly the oculomotor or third cranial nerve. The third nerve palsy of diabetes is characteristic, being of sudden onset, accompanied by orbital and retro-orbital pain, often associated with complete involvement of the external ocular muscles innervated by the nerve. While the human and experimental animal literature is replete with studies on the peripheral nerves in diabetes mellitus, there is but a paucity of reported studies dealing with the oculomotor nerves and their associated extraocular muscles (EOMs).

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