14-Year-Old Boy With Blurred Vision and Diplopia

Abstract

14-year-old boy presented to our emergency depart­ ment because of neck stiffness, diplopia, and blurred vision. He reported that the symptoms had begun 2 weeks earlier with a stiff neck after he had slept in a chair. Four days before presentation, he had noted mildly blurred vi­ sion, a holocephalic headache, and neck stiffness. The headache was relieved with acetaminophen. The morning before presentation, he complained of intermittent diplopia, and his parents took him to an optometrist for evaluation. On funduscopic examination, the optometrist observed blurred disk margins bilaterally. The patient was then referred to an ophthalmologist, who obtained a head computed tomographic scan, findings of which were nor­ mal. The patient was subsequently referred to our institu­ tion for evaluation. On presentation, the patient's only complaint was diplopia on right and left lateral gaze. He denied having headache, neck tenderness, change invisual acuity, nausea, or emesis. The general examination revealed an obese ado­ lescent male in no distress, with normal vital signs. Funduscopic examination showed indistinct optic disk margins bilaterally, retinal hemorrhages at the nasal margin of the left optic disk, and an absence of spontaneous venous pulsations. Diplopia was present on right and left lateral gaze, with an inability of the patient's left eye to ab­ duct fully on left lateral gaze. On the cover test, the lateral­ most image on both right and left lateral gaze was eliminated by covering the abducting eye. Findings on the rest of the neurologic examination were normal, in­ cluding visual fields, visual acuity, deep tendon reflexes, motor strength, sensory function, and cerebellar func­ tion. After the neurologic examination, the patient had a