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PUBLICATION EXCLUSIVE: Pediatric patient presents with new-onset diplopia and headache
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A 7-year-old boy presented to the Tufts Medical Center emergency department with a 2-week history of headache and 1-week history of binocular horizontal diplopia. He had no medical history. His ocular history was significant only for mild myopia for which he was already wearing glasses.
On evaluation in the emergency department, the patient endorsed a 2-week history of headache, which was associated with nausea, vomiting, decreased appetite and a 10-pound weight loss. The patient had taken Tylenol for the headaches without relief of symptoms. Additionally, the patient endorsed new-onset horizontal double vision over the past week. His parents noted that both eyes seemed to be turning inward. The patient also reported intermittently blurred vision in both eyes. He denied any episodes of complete loss of vision. He had no fevers, chills or rash. He denied any other focal neurologic complaints including weakness, numbness or tingling. The patient had no sick contacts. He denied any recent travel. Pediatric ophthalmology was consulted for evaluation of new-onset diplopia.
Examination
Initial bedside examination in the emergency department showed a best corrected visual acuity of 20/20 at near in both eyes. Both pupils were briskly reactive, and there was no relative afferent pupillary defect in either eye. Color vision, evaluated by Ishihara plates, was full in both eyes. Confrontational visual fields were full bilaterally. Extraocular muscle movements revealed bilateral abduction deficits (Figure 1). Alternate cover testing measured 20 D of esotropia in primary gaze at distance. The patient was orthotropic in primary gaze at near.
Bedside cranial nerve (CN) examination revealed intact CN V, VII, VIII, XI and XII bilaterally. The globes were soft to palpation. The eyelids and ocular adnexa were normal. No ptosis or lagophthalmos was noted. Bedside slit lamp biomicroscopy showed normal anterior segment architecture. No anterior or posterior cell was appreciated. Dilated funduscopic examination revealed bilateral optic nerve swelling with 360° of vessel obscuration and dilated, tortuous retinal veins. No disc hemorrhages or telangiectasias were noted. The posterior pole and peripheral retina were otherwise normal. OCT of the optic nerves confirmed bilateral optic nerve swelling (Figure 2) with average retinal nerve fiber layer (RNFL) thickness of 409 µm in the right eye and 370 µm in the left eye. OCT of the maculae demonstrated normal foveal architecture in each eye with mild nasal intraretinal edema tracking from the edematous optic nerves.
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- Click here to read the full publication exclusive,Grand Rounds at the New England Eye Center, published in Ocular Surgery News U.S. Edition, November 10, 2016.