The Case of a Woman with Intermittent Vision Loss. [Case Study #1]

If you ask me which sense is the most important of all, my answer would be the vision. However, once vision becomes impaired, patients can experience serious daily life problems.

_{Image by flickr under CC BY 2.0}

In this case, I will explain a case involving a 32-year-old woman who is referred to as "Ms. Z" who presented to the emergency department with intermittent vision loss ( intermittent meaning not continuous). Let's begin.

Patient's intro: Ms. X is 32 years old.

Chief Complaint: She had intermittent vision loss in her left eye.

She explained that she had been experiencing intermittent vision loss in her left eye for the past few weeks. Her vision would fade and then return to normal multiple times. Initially, she ignored it, but it became more frequent and began to affect her daily activities. She described the sensation as a "curtain" that would roll over her left eye, completely obstructing her vision for a few seconds before returning to normal. She also added it had happened only a few times before, but started occurring frequently in the last few days and it was more painful.

Doctors started examining her right away. But on her physical examination, everything was found to be within normal limits. Her vitals were normal, and she had a normal appearance. Other systemic examinations were also found to be unremarkable. By systemic I mean other systems of the body such as cardiovascular, respiratory, etc.

However, on her neurological examination, doctors noticed that her visual acuity was less in the left eye compared to the right eye. visual acuity just means clarity and the ability to recognize this at a distance. The rest of the physical examinations were unremarkable though.

The next step was to send her blood for testing. Her CBC or complete blood count was within normal limits but her CRP was found to be elevated. It was found to be more than 6mg/L. High levels of CRP in the blood indicate the level of inflammation in the body.

So, now doctors knew, there is inflammation in the body, but where? of course the first part to be suspected was the eye because it was painful. She was quickly sent for brain imaging or MRI.

MRI results showed that she had a significant abnormality in the left optic nerve, which was consistent with the symptoms of her left eye. Actually, her left optic nerve was swollen and inflamed as seen in the MRI reports. Also, there was significant demyelination in her left optic nerve.

The Clinical Symptoms, lab results, and MRI report suggested that she had a condition called "Optic Neuritis". Optic neuritis is a disease in which the optic nerve of the eye becomes inflamed or infected due to some reason. But was the diagnosis of Optic neuritis enough though?

She was finally treated for this condition with a dose of intravenous steroids to reduce the inflammation. She showed improvement in a few days and her vision became normal in her left eye. She is also able to return to her normal daily activities.

A few months later, she came back but this time the condition relapsed in her right eye. She was devasted as she knew she had to go through all the tests again. Did the doctors miss something before? she asked.

This time, the case was also reviewed by a neurologist. The neurologist suggested a new brain MRI but this time with contrast. Contrast is basically a dye that can highlight the inflamed areas, it's given through a vein. This time MRI revealed multiple lesions in the brain and also the spinal cord. The neurologist concluded that the findings are similar to "Multiple sclerosis".

What's multiple sclerosis now?

well, it's a disease where your own body's immune system attacks the nerve fibers and destroys the myelin sheath. Imagine myelin sheath as a protective covering for the nerve fibers. when it's destroyed, multiple scar tissues are formed, hence the name "multiple sclerosis". how common is it though? Nearly 1.2 million adults suffer from multiple sclerosis in the US alone. Yes, this is more common in females in their mid-30s. This can also cause long-term disabilities.

This article aims to raise awareness about the importance of early detection and treatment of multiple sclerosis, as it can be associated with other diseases and easily missed, particularly in young women. In Ms. X's case, a diagnosis of optic neuritis was not enough, and further investigations were required to reveal the underlying multiple sclerosis. Early detection and treatment can improve the prognosis and prevent long-term impairments.

Conclusion

This case highlights the importance of considering the presence of multiple sclerosis in a patient presenting with a painful eye and periodic loss of vision. Clinical examination, lab tests, and imaging led to the diagnosis of optic neuritis, but further investigations later revealed multiple sclerosis. This finding is significant, as multiple sclerosis could have been easily missed and led to long-term disability.

That's it for this article guys. See you at the Next one.

Previous articles:

Brief History of Anesthesia and its Working mechanism.
Should you get a hair transplant? How is it Performed?

References:

https://my.clevelandclinic.org/health/diseases/14256-optic-neuritis
https://www.nationalmssociety.org/What-is-MS