Unilateral Blurred Vision Research Articles

Orbital Tumor Misdiagnosed as Optic Neuritis in Rheumatoid Arthritis Patient: A Case Report

Abstract
 Introduction : Unilateral blurred vision and optic nerve swelling are the two most common signs of optic neuritis (ON). However, ON is rarely reported in patients with rheumatoid arthritis (RA), thus necessitating further diagnostic workup.
 Case Illustration : A 42-year-old woman visited our hospital with strabismus and progressive loss of vision in her left eye since three months ago. She had been treated with pulse dose steroid for suspected ON. She had been diagnosed with RA over five years and treated with immunomodulatory medication. Left eye examination revealed best corrected visual acuity of 20/50, proptosis, esotropia with painless limitation in temporal movement. Afferent pupillary defect (RAPD) and optic nerve swelling were present. OCT assessment revealed reduction in RNFL thickness. Further magnetic resonance imaging (MRI) investigation revealed a 2.35 x 2.6 x 1.8 cm mass in the left intraconal retrobulbar, in proximity to the medial optic nerve, which suggests a case of orbital Schwanoma. Excisional biopsy was performed and revealed a benign tumor.
 Discussion : Intraconal tumor may falsely be diagnosed as an optic neuritis in autoimmune patient. Neuro- ophthalmologic symptoms of systemic inflammatory in the optic nerve includes unilateral acute visual loss and pain in eye movement. Signs of ON includes RAPD, disc edema, and corresponding visual field defect. MRI of the optic nerve can assist diagnostic workup.
 Conclusion : The exact diagnosis of rheumatoid arthritis-associated ocular manifestations is challenging. Imaging using MRI might be needed to provide clarity in the diagnosis.

Unilateral blurred vision in pediatric patient associated with cavum velum interpositum cyst.

Unilateral blurred vision in pediatric patient associated with cavum velum interpositum cyst.

Vascular steal and associated intratumoral aneurysms in highly vascular brain tumors: illustrative case.

Intratumoral aneurysms in highly vascular brain tumors can complicate resection depending on their location and feasibility of proximal control. Seemingly unrelated neurological symptoms may be from vascular steal that can help alert the need for additional vascular imaging and augmenting surgical strategies. A 29-year-old female presented with headaches and unilateral blurred vision, secondary to a large right frontal dural-based lesion with hypointense signal thought to represent calcifications. Given these latter findings and clinical suspicion for a vascular steal phenomenon to explain the blurred vision, computed tomography angiography was obtained, revealing a 4 × 2-mm intratumoral aneurysm. Diagnostic cerebral angiography confirmed this along with vascular steal by the tumor from the right ophthalmic artery. The patient underwent endovascular embolization of the intratumoral aneurysm, followed by open tumor resection in the same setting without complication, minimal blood loss, and improvement in her vision. Understanding the blood supply of any tumor, but highly vascular ones in particular, and the relationship with normal vasculature is undeniably important in avoiding potentially dangerous situations and optimizing maximal safe resection. Recognition of highly vascular tumors should prompt thorough understanding of the vascular supply and relationship of intracranial vasculature with consideration of endovascular adjuncts when appropriate.

Teaching Video NeuroImage: Tadpole Pupil.

A 27-year-old healthy woman reported short episodes (15–30 seconds) of unilateral blurred vision in the left eye, during which an irregular shape of her left pupil was observed. She had no other symptoms. At presentation, pupils were equal in size and reactive to light, and there was no dilation lag, no eyelid ptosis, and eye motility was full. Diagnosis of tadpole pupil was made based on photographs taken by the patient herself (Figure) (Video 1). Because of a close association with Horner syndrome, sympathetic denervation hypersensitivity has been considered as an underlying mechanism. However, pharmacologic testing was negative (both cocaine 10% and apraclonidine 0.5%).

Unilateral blurred vision due to internal carotid artery occlusive disease

Unilateral blurred vision due to internal carotid artery occlusive disease

Dengue Maculopathy in a Traveler

A 35-year-old woman came to our hospital on November 22, 2010, after the onset of unilateral blurred vision and scotomata, purpuric rash over bilateral lower limbs, and metrorrhagia for four days. She had visited Vietnam for 11 days and fever, chills, and headache subsequently developed one day after returning to Japan. Fever and headache subsided six days after onset of disease. Laboratory data showed a platelet count of 109,000 cells/μL, dengue virus nonstructural protein 1, and IgM against dengue virus 10 days after onset of disease. Visual acuity was reduced to 20/25 in the left eye. Humphrey visual field testing showed nonspecific visual field defects. Funduscopic examination showed retinal hemorrhages and white spots (Figure 1). She was observed without treatment. Figure 1. Fundus photographs of right eye (A) and left eye (B) of a 35-year-old woman at initial examination (10 days after onset of disease), showing several retinal hemorrhages and white spots. Optical coherence tomography showed non-specific findings (C = right ... Blurring of vision and scotomata typically coincides with thrombocytopenia and clinical features include blot hemorrhages.1,2 Visual recovery usually corresponds with improving platelets levels, however, scotomata may persist for several weeks in some cases despite the resolution of ocular signs.1 The patient described small scotomata 19 days after onset of disease despite the resolution of thrombocytopenia and hemorrhagic spots (Figure 2). Her visual symptoms improved and visual acuity improved to 20/17 at 84 days after onset of disease. Figure 2. Fundus photographs of both eyes (A, C, and E = right eye; B, D, and F = left eye) of a 35-year-old woman 12 days after onset of disease (A and B), 19 days after onset of disease (C and D), and 84 days after onset of disease (E and F), showing gradual ...

Chorioretinopathia centralis serosa (CCS)

In the acute stage central serous chorioretinopathy (CSC) is characterized by serous retinal detachment. Monofocal or multifocal structural changes of the pigment epithelium layer are common. Unilateral blurred vision is the major clinical symptom. The pathogenesis is unclear but corticosteroids and stress may trigger the disease. Normal vision often returns spontaneously within a few months. Therapeutic options are at a low evidence level. Carbonic anhydrase, mild laser photocoagulation, selective retinal therapy, photodynamic therapy and the intravitreal injection of bevacizumab have been reported. The authors suggest a treatment strategy on the basis of the available data.

Endogenous Aspergillus Endophthalmitis Occurring After Liver Transplantation: A Case Report

Endogenous Aspergillus endophthalmitis (AE) is a rare complication of invasive aspergillosis in transplant patients. In this report, we have described a patient who underwent liver transplantation because of drug-induced cholestatic cirrhosis and developed AE at 2 weeks after the surgery. The patient was a 22-year-old man who received a right liver lobe from his father. The operation was uneventful but the patient developed signs and symptoms of small-for-size syndrome after the second day of surgery. The patient received intense immunosuppression with methylprednisolone for 3 days, tacrolimus and mycophenolate mofetil from the first day after the operation, with ceftriaxone and metronidazole as prophylactic antibiotics. Because of signs of respiratory distress with pneumonia, vancomycin and amphotericin B were added empirically to his regimen. Polymerase chain reaction for aspergillus DNA in the blood was positive. The patient received one course of methylprednisolone pulse therapy for signs of acute rejection at day 10, and tacrolimus was changed to sirolimus because of a rising serum creatinine and convulsions. After 2 weeks, the patient's symptoms improved and liver function tests were normal, but the complained of sudden intense pain in the left eye with unilateral blurred vision, redness, and other signs of endophthalmitis upon examination by an ophthalmologists. After 24 hours, visual acuity decreased to light perception. AE was confirmed by microscopy and culture of the vitreous fluid and retinal biopsy. Despite changing amphotericin to intravitreal injection of voriconazole followed by intravenous voriconazole and transient resolution of the symptoms, no improvement was seen in visual acuity. Pain and signs of inflammation in the eye recurred after 2 weeks. At last the patient underwent enucleation for resistant infection and fear of involvement of the other eye by aspergillosis or sympathetic ophthalmia.

Restored Photoreceptor Outer Segment Damage in Multiple Evanescent White Dot Syndrome

To report retinal tomography and function in the course of multiple evanescent white dot syndrome (MEWDS). Prospective case series. Seven patients with unilateral MEWDS. We performed optical coherence tomography (OCT), multifocal electroretinography (mfERG), full-field electroretinography (ffERG), fluorescein and indocyanine green angiography, and visual field examinations in 7 patients with active to resolved MEWDS. OCT imaging of the posterior fundus with a 6 x 6-mm square, best-corrected visual acuity (BCVA), fundus characteristics, visual field measurements, mfERG, and ffERG responses. All patients reported unilateral blurred vision and spotty visual field defects. The fundi had yellow or white dots of various sizes and extent in the affected eyes. The visual fields had enlarged blind spots in all affected eyes and scotomas in 3 of the 7 eyes. In 5 of the all fellow eyes, 4 fellow eyes had an enlarged blind spot, peripheral visual field defects, or both; 1 eye had only a peripheral field defect. OCT showed a disrupted or irregular photoreceptor inner/outer segment (IS/OS) junction line of varied extent in 7 affected eyes and 1 fellow eye. During 1.5 weeks to 6 months follow-up (mean, 3.4 months), the BCVA returned to 1.2 along with resolution of the white dots in all eyes. The IS/OS line was restored in 7 eyes, but 1 eye had focal disruption. The visual fields returned to normal in 5 affected eyes; however, an enlarged blind spot remained in 2 affected eyes and a peripheral defect remained in 2 fellow eyes. On ffERG and mfERG, the decreased responses recovered markedly in the 7 affected eyes. The lesions responsible for MEWDS appear to disrupt the photoreceptor outer segments; morphologic and functional recovery can occur. Although the symptoms and fundus lesions were visible unilaterally, the photoreceptor dysfunction was bilateral in most cases.

Optical Coherence Tomography Findings in Acute Retinal Pigment Epitheliitis

To report the optical coherence tomography (OCT) findings in three patients with acute retinal pigment epitheliitis (ARPE). Retrospective, observational case series. The charts of three patients with ARPE were reviewed. Approval from the Institutional Review Board was obtained. Fundus photographs, fluorescein angiograms, and OCT findings were examined. Three healthy, young patients presented with acute unilateral blurred vision. Ophthalmoscopy revealed fine pigment stippling surrounded by haloes of hypopigmentation. Fluorescein angiography demonstrated transmission hyperfluorescence. OCT showed abnormal foveal hyperreflectivity involving the outer nuclear layer and photoreceptors in all cases. Disruption of the retinal pigment epithelium (RPE) was seen in two cases. With resolution, the abnormal hyperreflectivity decreased in thickness. OCT confirms the involvement of the outer neurosensory retina in acute retinal pigment epitheliitis. RPE involvement may be a secondary post-inflammatory response, because one case did not have significant disruption of the RPE.

Ocular toxoplasmosis presenting as neuroretinitis: report of two cases

Background: Neuroretinitis is a clinical entity usually seen in young healthy adults, that is characterized by rapid profound unilateral loss of vision and includes optic nerve head edema, splinter hemorrhages, macular exudate in a stellate pattern, and variable vitreous inflammation. There are numerous entities that can cause a picture of neuroretinitis ranging from vascular to infectious to autoimmune. Patient and methods: We report two patients with neuroretinitis, who presented with unilateral blurred vision and had serologic evidence of Toxoplasma gondii infection. Results: Both patients responded well to treatment with systemic antibiotics and corticosteroids. Visual acuity returned to 20/60 in one patient and 20/20 in the other. Conclusion: Although the etiology is usually idiopathic, infectious causes of neuroretinitis, including toxoplasmosis, should be kept in mind in order to maintain visual acuity by early diagnosis and appropriate therapy.

Neurological abnormalities associated with CDMA exposure.

Dysaesthesiae of the scalp and neurological abnormality after mobile phone use have been reported previously, but the roles of the phone per se or the radiations in causing these findings have been questioned. We report finding a neurological abnormality in a patient after accidental exposure of the left side of the face to mobile phone radiation [code division multiple access (CDMA)] from a down-powered mobile phone base station antenna. He had headaches, unilateral left blurred vision and pupil constriction, unilateral altered sensation on the forehead, and abnormalities of current perception thresholds on testing the left trigeminal ophthalmic nerve. His nerve function recovered during 6 months follow-up. His exposure was 0.015-0.06 mW/cm(2) over 1-2 h. The implications regarding health effects of radiofrequency radiation are discussed.

Blunt-Trauma Carotid Artery Injury

Injury to the carotid artery can occur in athletes by direct blow to the neck or by hyperextension of the neck. After such injury, symptoms may be mild or transient. Catastrophic complications such as stroke can occur if the injury is not recognized and treated. Neurologic changes such as transient weakness or transient unilateral blurred vision that occur after a hyperextension injury or a direct blow to the neck may indicate a carotid artery injury. A careful neurologic examination can help identify most carotid artery injuries, but because the symptoms of injury may not appear immediately, follow-up may be necessary. Treatment may consist of anticoagulation therapy or operative repair.

Blunt-Trauma Carotid Artery Injury.

In brief Injury to the carotid artery can occur in athletes by direct blow to the neck or by hyperextension of the neck. After such injury, symptoms may be mild or transient. Catastrophic complications such as stroke can occur if the injury is not recognized and treated. Neurologic changes such as transient weakness or transient unilateral blurred vision that occur after a hyperextension injury or a direct blow to the neck may indicate a carotid artery injury. A careful neurologic examination can help identify most carotid artery injuries, but because the symptoms of injury may not appear immediately, follow-up may be necessary. Treatment may consist of anticoagulation therapy or operative repair.

Multiple Sclerosis-Like Syndrome in a Woman Heterozygous for Adrenoleukodystrophy

A 28-year-old asymptomatic woman was diagnosed to be heterozygous for adrenoleukodystrophy (ALD) by elevated very long-chain fatty acids in serum and fibroblasts after ADL had been diagnosed in her son. A year later she had transient unilateral blurred vision. Evoked potentials and brain magnetic resonance imaging showed further separate cerebral white matter lesions suggesting multiple sclerosis (MS). MS-like syndromes in women heterozygous for ALD may be more frequent than previously recognized.

Unilateral blurred vision and dilated retinal veins

A 39-year-old woman presented to her ophthalmologist complaining of floaters. This was associated with elevation of the optic disc and late staining of the retinal veins. The differential diagnosis of venous occlusive disease is discussed.

Visual disturbance and carotid artery disease. 500 symptomatic patients studied by non-invasive carotid artery testing including B-mode ultrasonography.

Non-invasive carotid artery testing was performed on 500 consecutive patients with visual disturbances not related to local ophthalmic pathology to determine the extent of carotid artery disease, particularly in patients with symptoms not typical of amaurosis fugax. Three hundred eighty six patients (77.2%) had an abnormal study. However, the incidence of hemodynamically significant lesions was only 16%. The patients could be divided into three groups: Patients with symptoms that could be explained on an ocular basis, including amaurosis fugax, had a 79% incidence of ipsilateral carotid plaques. Patients with symptoms which could not be easily explained on an ocular basis, such as bilateral blurred vision, bilateral visual loss (both transient and permanent), and homonymous hemianopsia had an incidence of carotid artery plaques similar to patients with amaurosis fugax. Patients with unilateral blurred vision and bilateral scintillations had a lower incidence (57%) of carotid plaques than the other groups. Younger symptomatic patients had less carotid plaques than the overall series. Twenty-one percent of patients under age 50 had the Doppler finding of early systolic flutter turbulence, which is usually of mitral valve origin. Women predominated in the under 50 age group by about 2:1. In view of the prevalence of carotid plaques in the population of patients with visual symptoms other than amaurosis fugax, evaluation of these patients with non-invasive testing is indicated to determine which of these patients has hemodynamically significant obstruction to flow at the carotid artery bifurcation.

An Alternative Approach to Prescribing in Selected Cases of Presbyopia

Unilateral near spectacle additions may be presented for selected presbyopic patients able to tolerate some degree of unilateral blurred vision for distance or near. This prescription offers some advantages of convenience and may be more acceptable for some vocational tasks than conventional multifocal spectacles, five successful case histories of patients with this prescription are reviewed.