A 64-year-old woman was seen at the ophthalmology clinic with a 1-day history of decreasing vision in her left eye. She reported that throughout the preceding 24 hours, she noted increasingly blurred vision in her left eye at both distance and near. She described the blurred vision as looking through a “veil.” She denied pain, diplopia, photophobia, flashing lights or floaters. She denied constitutional symptoms including headache, weakness, dizziness, weight loss, fevers, jaw claudication, scalp pain, myalgias, arthralgias or rashes.
The patient denied having an ocular history and reported that her last routine eye exam was 1 year before presentation. She had a medical history of hypothyroidism, for which she took daily levothyroxine. She denied all other medical conditions, including hypertension, diabetes and cancer, and denied prior surgeries. She was a nonsmoker and denied alcohol or drug use. She was divorced and lived alone with two grown children living locally.
On further questioning, she reported that 1 month before presentation, she began noticing a subtle retro-orbital pain on the left side. She described the pain as a vague, dull pressure sensation that would last approximately 10 minutes and then completely subside. The pain was unrelated to eye movement and occurred approximately three to four times a day. She had no other symptoms at the time. She was seen at a local emergency department and found to have a visual acuity of 20/20 in both eyes. She was sent home with artificial tears. She was set up with a follow-up community ophthalmologist but felt that the pain subsided during this time.
On initial examination, the patient’s vision was 20/20 in the right eye and hand motions in the left eye. She had a relative afferent pupillary defect in the left eye. IOPs were normal. Confrontation visual fields were full and color vision was normal in the right eye. She had proptosis of approximately 1 mm of the left eye and no restriction of extraocular movements. Anterior segment examination was notable only for moderate nuclear sclerotic cataracts in both eyes. Dilated fundus exam was unremarkable. The optic nerves were pink and the margins were sharp in both eyes.
Click here to continue reading the publication exclusive, Grand Rounds at the New England Eye Center, by Kendra Klein, MD.