Question

Create a case study about the vision system. Include a summary about what the symptoms, diagnosis, and treatments would be. Refer to chapter 11 and 12 on the textbook titled, " Neuroscience" (6th edition) by Dale Purves.

Textbook link: file:///C:/Users/tirbal/Downloads/Dale%20Purves%20et%20al.%20(eds.)%20-%20Neuroscience-Sinauer%20Associates%20(2018)%20(2).pdf

Answer 1

Patient History
HPI:
31 year-old female social worker who presents with 2 month history of fluctuating vision in both eyes. The blurriness has become more permanent in the R>L for the last 3 weeks. Vision is worse when lying down; at times her vision goes completely in both eyes. The peripheral vision is also affected (unable to see cars drive by unless turning head). Patient denies flashes or floaters. She has noticed some diplopia side to side when watching TV, occasionally, in the last 3 months.

She also reports headaches - intense and persistent- over her whole head for the last month. She though maybe due to the blurry vision. Headaches are also worse when lying down. She can also hear a whooshing sound in her ears once-in-a-while "as if I was listen to the waves".

Past Ocular History:
None

Ocular Medications:
None

Past Medical History:
Obesity

Surgical History:
None

Past Family Ocular History:
Negative for macular degeneration, glaucoma or other blinding diseases.

Social History:
No history of alcohol/tobacco/drug use. No STD risk.

Medications:
Multivitamin. No other medications in the past.

Allergies:
None

ROS:
No recent URI, no sick contacts. No other positive CNS, heart, lungs, GI, skin or joint sxs.

Ocular ex am

Visual Acuity (cc):
OD: 20/40
OS: 20/200

IOP (tonoapplantation):
OD: 13 mmHg
OS: 12 mmHg

Pupils:
Round and reactive bilaterally; positive APD L eye

Extraocular Movements:
Full OU. No nystagmus.

Confrontational Visual Fields:
Visual field defects superionasally and superiotemporally R eye. Visual field defects in all quadrants L eye.

External:
Normal, both eyes

Slit Lamp:

Lids and Lashes	Normal OU
Conjunctiva/Sclera	Normal OU
Cornea	Clear OU
Anterior Chamber	Deep and quiet OU
Iris	Normal OU
Lens	Clear OU
Anterior Vitreous	Clear OU

Dilated Fundus Ex amination:

OD	Clear view, CDR: 0.1 with blurry margins and obscure vessels; flat macula with normal foveal light reflex; normal vessels and peripheral retina
OS	Clear view, CDR 0 with significant elevation of the optic disc, obscured vessels and some disc hemorrhages; flat macula with normal foveal light reflex; normal vessels and peripheral retina

Other:
Humphrey Visual Field 24-2 OU - significant decrease of visual fields in both eyes with preserved central island of vision

MRI of the brain and orbits - large suprasellar mass abutting the R optic nerve and displacing the L optic nerve

Diagnosis
Bilateral optic nerve head swelling, due to intracranial mass

This patient presents with decreased vision bilaterally (visual acuity and visual field), an APD in the L eye and bilateral optic nerve head swelling. The MRI demonstrates an intracranial mass. Differential diagnosis of optic nerve head swelling also includes venous sinus thrombosis, idiopathic intracranial hypertension (or any other causes of increased intracranial pressure), and also causes of localized optic nerve swelling ie. severe hypertension, papillitis, optic nerve glioma

Symotoms

Visual disturbance

Visual blackouts often are triggered

Headache

increased intracranial pressure

nausea with vomiting and a machinery-like sound

Exa mination:
Key parts of the ocular ex am include visual acuity and visual field evaluation.

An APD will be noticeable if one nerve is more affected than the other. An ex amination of the optic nerve to determine if there is any swelling, obscuration of the optic nerve vessels, optic nerve hemorrhages, cotton-wool spots or atrophy is critical.

This can be done with the direct ophthalmoscope, the slit-lamp biomicroscope or the indirect ophthalmoscope.

Treatment:
In this case prompt evaluation by neurosurgery is needed to decompress the optic nerve sheath.

There is a high likelihood of permanent vision loss. In cases where the optic nerve head swelling is due to idiopathic intracranial hypertension oral acetazolamide is used to decrease the intracranial pressure and aid in decreasing optic nerve head swelling.

Optic nerve sheath fenestration is another option. The patient needs lifelong eye exa minations to ensure no further injury to the visual system.