What could cause blurred vision, double vision, headache and ocular pain in the left eye?
Patient's Query
Hello doctor,
I am 30 years old. In the past months I have had blurred vision, double vision, headache, and ocular pain in the left eye intensified with eyeballs movement. In the left eye, I have exophthalmos and eyelid ptosis. I had the same cohort of symptoms two years ago, and symptoms began a year ago and stopped six months after that. I did not receive a diagnosis for my problem. Three months after the symptoms began, an eyelid and upper limbs electromyography excluded myasthenia gravis (together with the blood test). I have attached my orbit MRI (magnetic resonance imaging) reports.
In the past two weeks, I had these exams:
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Brain CT (computed tomography) - Nerve optic.
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OCT (optical coherence tomography) - Brain, ocular orbits, and spine.
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MRI (magnetic resonance imaging) - Visual field study - Visual evoked potentials
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Neurological exam - Ophthalmological exam.
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Hess Lancaster test - Red desaturation test.
The results are as follows:
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Brain CT (computed tomography): Negative - Ocular orbits
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MRI (magnetic resonance imaging)(without gadolinium): Modest enlargement of both nerve optic sheaths (the left optic nerve sheath is larger than the right one).
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This scan was performed three days after the beginning of the symptoms.
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Ocular orbits, brain and spine MRI (magnetic resonance imaging) (with gadolinium): Negative, absence of MS (multiple sclerosis) lesions.
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Optic nerve OCT (optical coherence tomography): Negative.
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Visual field study: Normal.
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Visual evoked potentials. Left eye: P100 = 110-125 ms, and right eye: P100 = 106-118 ms.
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Neurological exam: Negative.
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Ophthalmological exam: Conjunctival hyperemia.
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Red desaturation test: Negative - Hess Lancaster test: negative.
Which diagnosis could I have? Waiting for your kind reply.
Thank you.
Hello,Welcome to icliniq.com.
I read your queries and understand your concern.Considering your description, extensive evaluations have been done to find the cause, without reaching a diagnosis. I have seen the scans you have attached. (Attachments removed to protect the patient's identity). I need to know the following:
1. If your exophthalmos and ptosis in the left eye started with the pain and blurred vision simultaneously?
2. Do you have any history of head trauma?
3. Have you experienced any episode of transient visual obscuration upon standing up or during pressure exertion (valsalva maneuver) like pressuring during defecation?
4. Have you had tinnitus?
Please write back with the answers so that we can come up with a diagnosis and treatment plan.
Regards.
Patient's Query
Hello doctor,
Thank you for your quick reply.
Here are the answers:
1. I have had ptosis and exophthalmos since I was 18 years old, so the symptoms did not start simultaneously.
2. I had a head trauma when I was a child (in brain MRI (magnetic resonance imaging) there is a lesion of a few millimeters in the right straight gyrus of the brain).
3. I did not experience any visual obscuration (I have never had a valsalva maneuver).
4. I rarely have tinnitus (when present it lasts a few seconds).
Thank you.
Hello,
Welcome back to icliniq.com.
I read your query and understand your concern.
Considering the data you have provided through your history and responses, and regarding the previously done para-clinic investigations, there are two possible differential diagnoses for your complaints:
1. Carotid-cavernous fistula.
2. Idiopathic intracranial hypertension. However, you do not have the typical features of any of them, but you may suffer from an atypical form.
To evaluate the mentioned diagnosis, you need to undergo the following studies:
1. Brain MRA (magnetic resonance imaging) and MRV (magnetic resonance venography) that give us a map of your brain vessels to seek any abnormal fistula between the carotid and cavernous sinus.
2. A lumbar puncture study to measure your intracranial pressure directly.
Please show my recommendation to your family physician. And feel free to inform me about the results.
Kind regards.
Patient's Query
Hello doctor,
Thank you for the reply.
In my previous brain MRA (magnetic resonance angiography), they found a possible infundibulum in the right internal carotid artery (ipsilateral A1 segment). The vessel is 2 millimeters larger than normal. What do you think about it?
Thank you.
Hello,
Welcome back to icliniq.com.
I read your query and understand your concern.
You did not mention that an MRA (magnetic resonance angiography) has been done. The site is not consistent with your left side problem, and in the presence of CCF (carotid-cavernous fistula), we expect more findings on MRA (magnetic resonance angiography) or MRV (magnetic resonance venography). Now, it is necessary to check your intracranial pressure.
Do write back if more queries are there.
Regards.
Patient's Query
Hello doctor,
Thank you for your reply. I need to ask one more question that is, is lumbar puncture the only solution?
Thank you.
Hello,
Welcome back to icliniq.com.
I read your query and understand your concern.
Regarding the increased CSF (cerebrospinal fluid) volume around your optic nerve, intermittent tinnitus, blurred vision, double vision, and eye and head pain, your intracranial pressure must be measured directly via lumbar puncture and the CSF (cerebrospinal fluid) composition should be analyzed in the laboratory. And yes, all of them are only possible via lumbar puncture.
I hope the answer helps you.
Regards.
Patient's Query
Hello doctor,
I wish to say thank you for your valuable responses.
Thank you.
Hello,
Welcome back to icliniq.com.
You are welcome, it is my duty as a doctor to help the patients. I wish you a good health.
Regards.
Patient's Query
Hello doctor,
I just performed a new MRA (magnetic resonance angiography) without gadolinium. The report is that the left vertebral artery is dominant. What does it mean? I have attached the images.
Thank you.
Hello,
Welcome back to icliniq.com.
I read your question and understand your concern. I am surprised by your swift action and the brain MRA (magnetic resonance angiography) does not show any significant anomaly (attachments removed to protect the patient's identity).
The dominancy of one vertebral artery is not clinically significant and is regarded as a normal variation.
I wish you good health and I hope my answers helped you.
Regards.
Patient's Query
Hello doctor,
Thank you for your response.
I am quite impulsive and I assure you I will take care of your health. Thank you so much.
Hello,
Welcome back to icliniq.com.
I am happy to help and you can write back whenever you have queries.
Warm regards.
Patient's Query
Hello doctor.
Thank you for the responses and yes I will get back if there are more queries I have. I wish you a good night.
Thank you.
Same symptoms don't mean you have the same problem. Consult a doctor now!
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