Mystery cases

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Mystery cases
UBC Clinical Neuroophthalmology Day- moderator
David Wakelin

1. Hockey-induced loss of the nasal fields
2. Wonky eye movements and lousy balance
3. Big nerve sheaths
4. Big cups and big-time visual loss
5. Brown discs
6. Swollen left disc plus
7. Swollen right disc

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• 1 the case of hockey-induced loss of the nasal
  fields
• 17 year old man with traumatic brain injury Nov
  04. Fell into boards while playing hockey, with
  intracranial hemorrhage and skull fracture. MRI
  reportedly showing signs of hypoxic injury.
• Post-injury he has impaired memory and cognitive
  deficits. He has a new exotropia and initially
  noted diplopia, but not since, and he has no
  visual complaints.
• VA 20/20 ou. Ishihara 16/16 ou. No RAPD.
• Orthoptics - relatively vertically and
  horizontally comitant 20-25 diopter exotropia,
  possible mild bilateral IV palsies.
• Pupils and lids normal.
• Fundus large physiological cups and bitemporal
  pallor.

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• 2 the case of wonky eye movements and lousy
  balance
• 33 year old man assault with loss of
  consciousness, seen for red eye OD and headache.
  Ophthalmologist funny eye movements. No visual
  loss, diplopia, or limited EOM prior to attack.
  Intermittently droopy eyelid in high school
  (offered surgery).
• Balance worsening over the past year, in
  retrospect poor in high school too.
• Tylenol 3. Medical history 0. Family history
  0. Smokes 1 ppd, mill worker.
• Acuity 20/30 ou. Colour plates 16 /16 ou, no
  RAPD. Full fields. Normal optic discs.
  Physiologic anisocoria. Variable mild right
  ptosis.
• Ductions diffusely limited to saccades and
  pursuit, upgaze and abduction most preserved, but
  full VOR range. XT in primary.
• Pursuit and VOR cancellation impaired. Saccades
  are small and limited in range, with inability to
  sustain eccentric gaze.
• No dysarthria. Rapid alternations slightly
  decreased. Impaired modified romberg, one-foot
  stance and tandem gait. Regular gait is wide
  based and slightly irregular.
• Reflexes diminished at the knees, with absent
  ankle jerks.

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Video 1. Vertical saccades 2. Horizontal
saccades 3. Horizontal saccades, one eye at a
time (better range) 4. Horizontal smooth pursuit
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Next slide Investigations
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EMG diminished H reflexes VEP prolonged OU MRI
cerebellar atrophy, especially of vermis, with
mildly larger IV ventricle Pending
neurogenetics consult and testing Cholesterol,
TG, LDL and HDL Anti-GQ1b Antibody?
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• 3 the case of the big sheaths
• 71 year old man seen in stroke clinic for
  intermittent facial numbness, referred because of
  big optic nerve sheaths on MRI.
• ASA, folate, allopurinol, atorvastatin,
  metoprolol
• Angina with coronary angioplasty, hypertension,
  gout, hyperkalemia with renal dysfunction.
  Brother with diabetic retinopathy
• 20/20 ou, mild hyperopia (1.00). Colour plates
  15/16 od and 13.5/16 os. No RAPD. Confrontation
  fields full. EOM normal
• Neurological exam normal.
• MRI report bilateral focal fluid within the
  optic nerve sheath immediate posterior to the
  oculus.

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4. The case of cupped discs and big-time visual
loss year old woman with gradually decreasing
peripheral vision, first noted on driving
assessment. In the last year some deterioration
in vision os. No other neurological
symptoms. Seen two years prior for extensive
optic nerve head cupping, diagnosed as probable
normal tension glaucoma. 20/40 od and count
fingers 1 os. Left RAPD. Mild subcapsular
cataracts ou. IOP 13 od and 12 os. Pale discs
with deep cups (C/D ratio 0.95 ou).
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HVF 30-2 fields from Aug 2003
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HVF 30-2 fields from Aug 2005
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5. The case of the brown discs 52 year old
woman seen for abnormal discs. 2 years of blurry
vision, floaters OS, burning sensation OU in the
morning or with reading. Medication None.
Prior Hepatitis B. C-section 25 years ago. Jan
05 laser treatment in Taiwan OS for retinal
hole. Family history high blood pressure
VA 20/20 OU. Color plates 16/16 OU. No RAPD.
Confrontation fields full. PVD OS. Pupils and
lids symmetric. Blepharitis and dry eyes ou.
Small comitant exophoria. Neurological
examination normal. Goldmann perimetry normal.
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Question what causes brown optic discs?
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6. The case of the swollen left disc plus 42
year old woman with visual loss os of 20
months. Jan 04 1. pain, tingling and swelling of
left arm, spreading to left face, trunk and
limbs, improving 10 months later, leaving small
numb spot left jaw. 2. painless blurry vision os,
progressing over 10 months, stable since. First
exam at 10 months disc edema with peripapillary
infiltrates, cystoid macular edema.
Medications mobicox arthritis for 6 years.
ulcers. Past surgery tubal ligation
95 Allergies bee stings, plaquenyl. Family
history 5 brothers, one with arthritis, one with
Crohns, 3 sisters, one with DVT, one with SLE,
one with alopecia. 2 sons, one with ulcerative
colitis. Parents had arthritis. VA 20/15 od and
20/60 os. Color plates 13.5/14 od and 1/14 os.
RAPD os. Confrontation fields cecocentral and
inferonasal depression os. Pupils, lids
symmetric, EOM normal. Neurological exam no
facial or limb sensory loss.
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Next page fundus photos OU
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Next page enlarged view OS
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Next page fluorescein angiogram
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Next page ..investigations
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Prior Investigations CRP 17.19 normal ACE,
anti-DNA, ENA, ANA, Rh factor, ANCA normal TB
skin test, chest X-ray. MRI report - white
matter changes, non-specific, possible
vasculitis CSF 2 wbc, 35 rbc, protein normal
.39, one oligoclonal band, negative AFB VEP os
127ms, od 109 ms, in Jan 05 and Apr 05 pending
- lyme. New investigations VDRL
negative Gallium scan and CT chest
pending Bartonella serology positive at 1320
"presumptive evidence of recent infection"..
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8. The case of the swollen right disc 39 year
old male with 5 weeks of intermittent, sometimes
postural TVOs OD, lasting up to 10
seconds Increasing in frequency 15-20
times/day Feels vision OD is no longer normal
between attacks Meds zoloft, fentanyl
patch Allergies morphine SHx single, on
disability for 5 years for back injury, 6
beers/week, non-smoker 20/40 OD, 20/20 OS,
Colour plates 16/16 ou, colour desaturation OD.
Subtle RAPD OD
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Next slide Goldmann fields..
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• LP normal opening pressure
• MRI normal
• Serology
• ANCA negative
• Lyme negative
• RF negative
• ACE normal
• Toxoplasma negative
• RPR reactive
• FTA-ABS reactive
• HIV positive
• IV aqueous crystalline penicillin G
• 2 to 4 million U q 4h for 12 to 4 million U q 4h
  for 1 days
• Benzathine penicillin 2.4 million U IM q weekly
  for 3 weeks

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Follow up 20/30 od, 20/20 os