Visual disturbances

Visual disturbances of unknown etiology
Short Summary

A 43 years old woman man who presented with various symptoms consisting of visual disturbances, burning sensation in the eyes, headache, hypersensitivity to noise and dizziness. Repeated neurological examinations were reported normal. A thorough neurological work-up that included blood tests, brain MRI, EEG and echocardiography was normal.
 

Patient's Questions

1. What diagnosis would you suggest?
2. Which can be the possible causes of the described disorder?
3. What therapy do you recommend?
4. Any center of excellence for the treatment of this pathology?
 

Medical Background

A 43 yearrs old female.
For the last year, the patient suffers from steady “moving spots” in her vision. This visual disorder is very similar to the image sent back from a badly syntonized television screen or a computer monitor on which the single pixels, that make up the image, can be distinguished. In the dark the image is not uniform but it is made up of lots of moving spots, as if on a black background there were brighter moving spots.
The vision of spots persists also when the patient’s eyes are closed as on a screen with brighter spots.
Moreover, the patient shows a difficulty in keeping the eyes focused when reading, in fact she often needs to avert her eyes from the paper sheets bringing them back to the pages after a while. She often feels a burning sensation in the eyes in front of the video terminal screen.
A constant variably localized headache is associated, sometimes at the frontal level, other times at the parietal level and some other times at the occipital level. But it affects more frequently the left side of the head.
For several months the patient has reported waking up during the night between 3:00 am and 3:30 am because of a diffuse heat at the upper part of the head or of a strong headache. Furthermore, when in lying position she suffers from dizziness. The patient suffers from a marked disorder due to noises that she previously tolerated much more. She shows a more frequent irritability besides a sensation of confusion and disorientation.
The patient reports that for the last 17 years, because of her job, she is exposed continuously to the video terminal from 8:30 am to 1:30 pm and from 2:40 pm to 5:20 pm.

From the clinical point of view she carried out some medical tests and specialist visits among which:
- Ophthalmology visit: Confirmation of lazy right eye (occurred after measles when she was a child) not capable of improvement. Acknowledging the reported “snow vision”, there is no evidence of connectable eye abnormalities.
- Neurological examination: Negative neurological objective examination. Therefore, the clinical picture does not allow a single pathological interpretation. Diagnostic in-depth medical tests are advised among which EEG, echocardiography, blood tests (vitamin B12, antiphospholipids Ab, Ft3, Ft4, TSH, routine blood chemistry tests) and possible brain MRI without contrast medium.
The results of the tests were:
- EEG: Absence of pathologic signs.
- Color doppler echocardiography: Morphological and functional findings within normal limits.
- Brain MRI: Normal findings.

Further neurological examination, after the examination of the medical tests carried out:
Ophthalmology and orthoptic visit carried out. Thyroid function within normal limits. 
At the objective neurological examination: Within normal limits; in particular no dysfunction of extrinsic and intrinsic eye movability. Brisk DTRs, Babinski reflex. No appreciable bruits on auscultation over the carotid arteries.
The conclusions are: “The disorder reported by the patient does not show the typical characteristics for a correct nosographic picture, nor the examinations, already carried out, suggest an organic origin. An ERG-visual evoked potentials exam should also be considered. The appearance of headache also in the night with negative brain MRI suggests much more a tension origin. Advised therapy: Laroxyl 3 drops in the evening for 5 days then 5 drops in the evening for 2 months; Xanax 5 drops at 8:00 a.m. + 8 drops at 2 p.m. + 10 drops at 8:00 p.m. for 2 months; Samyr 400 mg 1 intramuscular injection vial for 15 days.”

In consideration of the absence of a specific diagnosis, the patient deemed it necessary to avoid taking drugs nor to undergo other therapies, except for some acupuncture treatments that improved the headache but had no results on the sight.
 

Expert's Opinion

This is a second opinion based on the attached clinical information. I have not performed a clinical examination of the patient. This second opinion has been requested on behalf of the patient by medical-opinion.

This is a 43 years old woman man who presented with various symptoms consisting of visual disturbances (blurring of vision, “moving spots” in the visual fields); difficulties in focusing her eyes; burning sensation in the eyes; sleep disturbances due to heat sensation in the head; hypersensitivity to noise.

Repeated neurological examinations were reported normal. A thorough neurological work-up that included: brain MRI, EEG, echocardiography was normal.
Blood tests were also normal.

To my opinion, these symptoms do not correlate with a specific neurological disorder and cannot be explained by a specific lesion in the nervous systems. Theoretically, “moving spots” and visual blurring could be due to ophthalmic problems, but this has been ruled out in the ophthalmologic examinations.
It is likely that the symptoms may be at least in part secondary to emotional stress, and I strongly suggest that she also consults a psychiatrist.

It seems to me that she had undergone a thorough investigation. I would be happy to be of any further help if needed.

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