A 26-Year-Old Man with Blurred Vision  

Oleh:

Cestari, Dean M. ; Metson, Ralph B. ; Cunnane, Mary E. ; Faquin, William C.

Jenis: Article from Journal - ilmiah internasional
Dalam koleksi: The New England Journal of Medicine (keterangan: ada di Proquest) vol. 359 no. 26 (Dec. 2008), page 2825-2834.
Topik: Blurred vision

Ketersediaan

Perpustakaan FK Nomor Panggil: N08.K.2008.06 Non-tandon: 1 (dapat dipinjam: 0) Tandon: tidak ada

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Dr. Aaron Savar (Neuro-Ophthalmology): A 26-year-old man was seen in the Neuro-Ophthalmology Clinic of the Massachusetts Eye and Ear Infirmary (MEEI) because of blurred vision in the right eye. Approximately 8 days earlier, vision in the right eye became hazy, and periorbital pain developed. Six days earlier, he was evaluated in the emergency department of this hospital. He had recently had an upper respiratory infection and nasal congestion, for which he was taking pseudoephedrine. The vital signs and general physical examination were normal. He was referred to the emergency department of the MEEI. He rated the discomfort of the right eye as 2 to 3 on a scale of 0 to 5, where 5 is the most severe. Visual acuity, with eyeglasses, was 20/50 in the right eye and 20/20 in the left eye. The pupils were 4 mm in diameter. Motility was normal, as were the results of a confrontational visual-field examination (whereby the examiner sits directly in front of the patient, who, with one eye covered, is asked to look at the examiner's eye and announce when the examiner's hand is visible as it moves from the periphery toward fixation) and a slit-lamp examination. A diagnosis of blepharitis was made, and treatment with warm compresses was recommended. During the next 5 days, visual acuity in the right eye gradually decreased, and the patient felt mild discomfort with movement of the eye. Nasal congestion and headache persisted, and he continued to take pseudoephedrine. One day before admission, he returned to the emergency department of the MEEI. He again rated the discomfort of the right eye as 2 to 3. On reexamination, the blood pressure was 150/83 mm Hg and the pulse 104 beats per minute. Visual acuity, with eyeglasses, was 20/60 +1 in the right eye and 20/20 in the left eye. Both pupils constricted more after illumination of the left eye than after illumination of the right eye (indicating a relative afferent pupillary defect in the right eye). Motility and a confrontational visual-field examination were normal in both eyes, and applanation tonometry revealed intraocular pressures of 16 mm Hg on the right and 17 mm Hg on the left. On funduscopic examination, the optic nerve of the right eye appeared swollen. Magnetic resonance imaging (MRI) scans, obtained before and after the administration of gadolinium, revealed bilateral nasal polypoid lesions, a finding consistent with inflammatory polyps, mucosal thickening in all paranasal sinuses, and expansion of a left anterior ethmoid air cell, thought to represent a mucocele. The left aspect of the bony sella was elevated, with superior displacement of the normal-appearing pituitary gland, which abutted the optic chiasm. No signal abnormality was noted in the optic nerves on T2-weighted images. There was no enhancement along the course of the optic nerves. Intranasal corticosteroids and a tapering course of methylprednisolone were begun. The next day, the patient was seen by the Neuro-Ophthalmology Service. The patient did not have rashes, fevers, myalgias, numbness, weakness, or ataxia. He had had chronic sinusitis for approximately 5 years. He was born in India and had immigrated to the United States 2 years earlier. Medications included pseudoephedrine, intranasal steroids, and methylprednisolone. He had no allergies to medications, and he did not smoke, drink alcohol, or use illicit drugs. On examination, the patient was alert, oriented, and cooperative. There was nasal congestion and copious discharge. The best corrected visual acuities were 20/40 in the right eye and 20/15 in the left eye, with no improvement with pinhole testing (viewing the chart through a pinhole). Results of the Ishihara color-vision test revealed that he was colorblind in the right eye and had normal color vision in the left eye. Testing with the use of an Amsler grid showed diffuse metamorphopsia (distortion of the straight lines of the grid) on the right. The pupils were equal in size, and constricted in response to light and while focusing on an approaching object (near stimulus). The right relative afferent pupillary defect was again demonstrated. External examination of the eyes and orbits was normal. The eyelids were in normal position and ocular motility was normal. The slit-lamp examination revealed normal anterior segments bilaterally. Applanation tonometry revealed pressures of 17 mm Hg in both eyes. Automated perimetry testing (also known as Humphrey visual-field testing) was performed reliably in both eyes and was normal in the left eye. The right eye showed a diffusely decreased visual field with an area of relative sparing superonasally. Stereoscopic funduscopy performed while the pupils were dilated revealed swelling of the right optic nerve, more prominent nasally than temporally. There were no optociliary collateral vessels. The left optic nerve was normal. The maculae and mid-peripheral retinas were normal in both eyes. The next day, computed tomography (CT) of the orbits and sinuses, performed after the administration of contrast material, revealed extensive radiodense material in the paranasal sinuses, the ethmoid air cells, and the sphenoid sinuses, with expansion of ethmoid air cells and the sphenoid sinuses. There was erosion of both optic canals, the floor of the sphenoid sinus, and the sella turcica. There was mass effect on the pituitary gland, which was displaced superiorly and to the right by the expanded left sphenoid sinus. The next day, the patient was admitted to the MEEI and a diagnostic procedure was performed.

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