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I’ve Had Chronic Problems With The Vision In My Right
Question: I’ve had chronic problems with the vision in my right eye for years, I can’t seem to be given the right prescription for glasses or contacts. I’ve seen multiple optometrists, two ophthalmologists and a neuro-ophthalmologist who sent me for an MRI of the brain, which was normal.
My vision is distorted, blurry, sometimes even double in the right eye. If I shut my good eye (left) I’ll notice a sort of flicking aura in the peripheral vison in my right eye.
One optometrist said I had an astigmatism, but the adjustment to my glasses didn’t help. My right pupil seems closer to the nose or somewhat uneven compared to the left eye.
I’m at a loss of what to do.
I’ll note that I have visual migraines (Scintillating scotoma) and the neuro-ophthalmologist suggested it could be a varient of a persistant migraine aura, but said there was nothing more he could do for me.
My vision is distorted, blurry, sometimes even double in the right eye. If I shut my good eye (left) I’ll notice a sort of flicking aura in the peripheral vison in my right eye.
One optometrist said I had an astigmatism, but the adjustment to my glasses didn’t help. My right pupil seems closer to the nose or somewhat uneven compared to the left eye.
I’m at a loss of what to do.
I’ll note that I have visual migraines (Scintillating scotoma) and the neuro-ophthalmologist suggested it could be a varient of a persistant migraine aura, but said there was nothing more he could do for me.
I’ve had chronic problems with the vision in my right eye for years, I can’t seem to be given the right prescription for glasses or contacts. I’ve seen multiple optometrists, two ophthalmologists and a neuro-ophthalmologist who sent me for an MRI of the brain, which was normal.
My vision is distorted, blurry, sometimes even double in the right eye. If I shut my good eye (left) I’ll notice a sort of flicking aura in the peripheral vison in my right eye.
One optometrist said I had an astigmatism, but the adjustment to my glasses didn’t help. My right pupil seems closer to the nose or somewhat uneven compared to the left eye.
I’m at a loss of what to do.
I’ll note that I have visual migraines (Scintillating scotoma) and the neuro-ophthalmologist suggested it could be a varient of a persistant migraine aura, but said there was nothing more he could do for me.
My vision is distorted, blurry, sometimes even double in the right eye. If I shut my good eye (left) I’ll notice a sort of flicking aura in the peripheral vison in my right eye.
One optometrist said I had an astigmatism, but the adjustment to my glasses didn’t help. My right pupil seems closer to the nose or somewhat uneven compared to the left eye.
I’m at a loss of what to do.
I’ll note that I have visual migraines (Scintillating scotoma) and the neuro-ophthalmologist suggested it could be a varient of a persistant migraine aura, but said there was nothing more he could do for me.
Brief Answer:
Retinal migraine can be with or WITHOUT headache
Detailed Answer:
Good evening to a former resident of Montreal.
I was looking at the map trying to figure out if I could recognize the part of Montreal you were in but unfortunately I could not see anything terribly familiar. We were there in 1967 for EXPO 67 when I got lost in La Ronde....that I clearly remember! And we lived in a set of large apartment buildings on DeCarrie Blvd in the same year they opened the subway system...Our station was ATWATER.....I got lost on that thing too which drove my parents nuts! HAHA.... decades later, a fellow resident of that beautiful city I loved while we were there.
Let's take a look at a couple of things that I need to make assumptions on right away because of what you said on your multiple visits to a variety of doctors. You say you've been to multiple optometrists AND ophthalmologists who can't find anything really STRUCTURALLY WRONG with the eye or the periorbital contents....and I'll have to take that as a GIVEN though the phenomenon of the right eye problems on a background of MONOCULAR DIPLOPIA (double vision in only 1 eye) and SCINTILLATING SCOTOMA that appears right sided (when left eye is closed).....is rather difficult to reconcile purely on a NEUROLOGICAL BASIS.
Monocular diplopia is especially difficult to explain and in fact, we teach our residents that if a patient complains of double vision in 1 eye (which has been corroborated through proper confrontational testing) that there is about a 99.9% chance of there be a structural lesion within the globe itself and often times it is in the retina or the optic nerve head. Diplopia in only 1 eye simply has no Central Nervous System (CNS- neurological) explanation except when possibly consideration some wild variation of a zebra disease (i.e. RARE). A search of the literature will literally show you the following causes of such double vision:
refractive errors, corneal disease (e.g., irregular astigmatism), iris lesions, cataracts, and macular disease.
Primary or secondary visual cortical diseases can be rarely associated with monocular diplopia or even MORE THAN 2 IMAGES (cerebral polyopia) but we are probably talking about a COUNTABLE # of cases described in the literature. Personally, I've only seen verifiably documented case of monocular diplopia due to CNS in someone with demyelinating disease where white matter lesions were so strategically placed that you would likely never be able to replicate that patient's condition again. They actually converted from a diplopic condition to XXXXXXX blurriness after about 6 months on a background of OPTIC NEURITIS....so was the diplopia just a prelude to something else down the road? Hard to say.....
But now, here is the interesting part of your story....SUPPORT for an underlying CNS cause to this problem lies in the fact that the diplopia only seems to exist with the left eye CLOSED or obstructed by a prism. When I test my patients for this sort of problem I prefer they not CLOSE the good eye simply sometimes you can't tell whether just the act of closing the eye itself may be causing some aberration of visual perception in the fellow eye....some people really love to SCRUNCH that good eye closed and that could alter all sorts of muscle activity on the "bad side"....make sense?
And so, if the RIGHT EYE really had some type of structural or pathophysiological problem that was OUTSIDE THE CNS proper.....then, I'd expect you to be telling me that even with the LEFT eye open....you would still be experiencing some type of diplopic vision.
So now we come to what rare birds in the CNS can cause diplopic vision of a monocular type and the answer is....RETINAL MIGRAINES (with or without severe headaches). And the support for this diagnosis may be from your complaints of scintillating scotoma or phosphenes as I commonly refer to them in my headache patients. Retinal migraines can come with or without the killer headache and I'm going to assume you don't really have a headache or I'm sure you would've said something to that effect.
However, let it be known that RETINAL MIGRAINES that can have as a typical feature UNILATERAL PHOSPHOGENIC ACTIVITY (scintillating scotoma) as well as MONOCULAR DIPLOPIA still are usually found to have some type of odd or rare intraocular or periocular pathology...retinal disease for example (retinitis pigementosa....I've seen one case of that so far when a headache patient once came to me with similar complaint)....however, that is usually easy to pickup on fundoscopy when one knows what they're looking at and so I find it hard to believe that 4 ocular specialists would miss it...even though it is a rare bird diagnosis.
You say that an MRI was performed....was it done with GADOLINIUM CONTRAST and was it done with FINE CUTS THROUGH THE OTPIC NERVES up to the CHIASM? That is how I would typically order the MRI scan on someone such as yourself if I were confronted with the ocular symptoms and an ALL CLEAR from my ophtho colleagues.
I would also make sure you got VISUAL EVOKED POTENTIALS (VEP) since that test is sensitive (though not specific for location and prone to variability and error for many reasons...but it's still a very good test to verify an INTACT VISUAL PATHWAY SYSTEM) for optic nerve transmission failure which could be due to any number of system failures from the time light HITS the eye to when it is processed in the occipital.
Once again, relying on the fact that you've had at least 3-4 funduscopic evaluations (perhaps even loaded up with a few liters of FLUORESCEIN dye! LOL), dilated eye exams, perimetry testing, etc. and nothing seems to be turning up then, I think the clinical utility of a VEP would be to demonstrate NORMAL RESPONSES.....yes, you heard me correctly. I'd really be looking for the test in this case to be NORMAL which would tell me the visual pathways are not to blame for your symptoms. Unfortunately, it doesn't tell me what is the problem and sort of throws the ball back into the ophthalmologist's court.
A more sensitive type of VEP test is available called the MULTIFOCAL VEP which can discern more precise topographic abnormalities in the visual pathways that are diseased or abnormal than the standard VEP....and perhaps that would be something to consider.
Therefore, and to wrap this XXXXXXX treatise up....I might approach you in the following way with your symptoms:
1. MRI of the head with gadolinium contrast with OPTIC NERVE protocol as described above
2. VEP or mfVEP testing (goal is to see if the testing is NORMAL). Of course, if abnormal, more assessment required.
3. Consideration of oddball things such as RETINAL MIGRAINES
If I've provided useful or helpful information could you do me a HUGE favor by CLOSING THE QUERY and taking a moment to provide a few kind words of feedback, perhaps even stamping the consult with a 5 STAR rating if you feel so inclined?
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in being kept in the loop with how things progress so please drop me a line whenever you seem to be turning the corner or if you end up getting some testing done. I'm happy to give you opinions on those issues as well.
This query has utilized a total of 60 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Retinal migraine can be with or WITHOUT headache
Detailed Answer:
Good evening to a former resident of Montreal.
I was looking at the map trying to figure out if I could recognize the part of Montreal you were in but unfortunately I could not see anything terribly familiar. We were there in 1967 for EXPO 67 when I got lost in La Ronde....that I clearly remember! And we lived in a set of large apartment buildings on DeCarrie Blvd in the same year they opened the subway system...Our station was ATWATER.....I got lost on that thing too which drove my parents nuts! HAHA.... decades later, a fellow resident of that beautiful city I loved while we were there.
Let's take a look at a couple of things that I need to make assumptions on right away because of what you said on your multiple visits to a variety of doctors. You say you've been to multiple optometrists AND ophthalmologists who can't find anything really STRUCTURALLY WRONG with the eye or the periorbital contents....and I'll have to take that as a GIVEN though the phenomenon of the right eye problems on a background of MONOCULAR DIPLOPIA (double vision in only 1 eye) and SCINTILLATING SCOTOMA that appears right sided (when left eye is closed).....is rather difficult to reconcile purely on a NEUROLOGICAL BASIS.
Monocular diplopia is especially difficult to explain and in fact, we teach our residents that if a patient complains of double vision in 1 eye (which has been corroborated through proper confrontational testing) that there is about a 99.9% chance of there be a structural lesion within the globe itself and often times it is in the retina or the optic nerve head. Diplopia in only 1 eye simply has no Central Nervous System (CNS- neurological) explanation except when possibly consideration some wild variation of a zebra disease (i.e. RARE). A search of the literature will literally show you the following causes of such double vision:
refractive errors, corneal disease (e.g., irregular astigmatism), iris lesions, cataracts, and macular disease.
Primary or secondary visual cortical diseases can be rarely associated with monocular diplopia or even MORE THAN 2 IMAGES (cerebral polyopia) but we are probably talking about a COUNTABLE # of cases described in the literature. Personally, I've only seen verifiably documented case of monocular diplopia due to CNS in someone with demyelinating disease where white matter lesions were so strategically placed that you would likely never be able to replicate that patient's condition again. They actually converted from a diplopic condition to XXXXXXX blurriness after about 6 months on a background of OPTIC NEURITIS....so was the diplopia just a prelude to something else down the road? Hard to say.....
But now, here is the interesting part of your story....SUPPORT for an underlying CNS cause to this problem lies in the fact that the diplopia only seems to exist with the left eye CLOSED or obstructed by a prism. When I test my patients for this sort of problem I prefer they not CLOSE the good eye simply sometimes you can't tell whether just the act of closing the eye itself may be causing some aberration of visual perception in the fellow eye....some people really love to SCRUNCH that good eye closed and that could alter all sorts of muscle activity on the "bad side"....make sense?
And so, if the RIGHT EYE really had some type of structural or pathophysiological problem that was OUTSIDE THE CNS proper.....then, I'd expect you to be telling me that even with the LEFT eye open....you would still be experiencing some type of diplopic vision.
So now we come to what rare birds in the CNS can cause diplopic vision of a monocular type and the answer is....RETINAL MIGRAINES (with or without severe headaches). And the support for this diagnosis may be from your complaints of scintillating scotoma or phosphenes as I commonly refer to them in my headache patients. Retinal migraines can come with or without the killer headache and I'm going to assume you don't really have a headache or I'm sure you would've said something to that effect.
However, let it be known that RETINAL MIGRAINES that can have as a typical feature UNILATERAL PHOSPHOGENIC ACTIVITY (scintillating scotoma) as well as MONOCULAR DIPLOPIA still are usually found to have some type of odd or rare intraocular or periocular pathology...retinal disease for example (retinitis pigementosa....I've seen one case of that so far when a headache patient once came to me with similar complaint)....however, that is usually easy to pickup on fundoscopy when one knows what they're looking at and so I find it hard to believe that 4 ocular specialists would miss it...even though it is a rare bird diagnosis.
You say that an MRI was performed....was it done with GADOLINIUM CONTRAST and was it done with FINE CUTS THROUGH THE OTPIC NERVES up to the CHIASM? That is how I would typically order the MRI scan on someone such as yourself if I were confronted with the ocular symptoms and an ALL CLEAR from my ophtho colleagues.
I would also make sure you got VISUAL EVOKED POTENTIALS (VEP) since that test is sensitive (though not specific for location and prone to variability and error for many reasons...but it's still a very good test to verify an INTACT VISUAL PATHWAY SYSTEM) for optic nerve transmission failure which could be due to any number of system failures from the time light HITS the eye to when it is processed in the occipital.
Once again, relying on the fact that you've had at least 3-4 funduscopic evaluations (perhaps even loaded up with a few liters of FLUORESCEIN dye! LOL), dilated eye exams, perimetry testing, etc. and nothing seems to be turning up then, I think the clinical utility of a VEP would be to demonstrate NORMAL RESPONSES.....yes, you heard me correctly. I'd really be looking for the test in this case to be NORMAL which would tell me the visual pathways are not to blame for your symptoms. Unfortunately, it doesn't tell me what is the problem and sort of throws the ball back into the ophthalmologist's court.
A more sensitive type of VEP test is available called the MULTIFOCAL VEP which can discern more precise topographic abnormalities in the visual pathways that are diseased or abnormal than the standard VEP....and perhaps that would be something to consider.
Therefore, and to wrap this XXXXXXX treatise up....I might approach you in the following way with your symptoms:
1. MRI of the head with gadolinium contrast with OPTIC NERVE protocol as described above
2. VEP or mfVEP testing (goal is to see if the testing is NORMAL). Of course, if abnormal, more assessment required.
3. Consideration of oddball things such as RETINAL MIGRAINES
If I've provided useful or helpful information could you do me a HUGE favor by CLOSING THE QUERY and taking a moment to provide a few kind words of feedback, perhaps even stamping the consult with a 5 STAR rating if you feel so inclined?
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in being kept in the loop with how things progress so please drop me a line whenever you seem to be turning the corner or if you end up getting some testing done. I'm happy to give you opinions on those issues as well.
This query has utilized a total of 60 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Brief Answer:
Retinal migraine can be with or WITHOUT headache
Detailed Answer:
Good evening to a former resident of Montreal.
I was looking at the map trying to figure out if I could recognize the part of Montreal you were in but unfortunately I could not see anything terribly familiar. We were there in 1967 for EXPO 67 when I got lost in La Ronde....that I clearly remember! And we lived in a set of large apartment buildings on DeCarrie Blvd in the same year they opened the subway system...Our station was ATWATER.....I got lost on that thing too which drove my parents nuts! HAHA.... decades later, a fellow resident of that beautiful city I loved while we were there.
Let's take a look at a couple of things that I need to make assumptions on right away because of what you said on your multiple visits to a variety of doctors. You say you've been to multiple optometrists AND ophthalmologists who can't find anything really STRUCTURALLY WRONG with the eye or the periorbital contents....and I'll have to take that as a GIVEN though the phenomenon of the right eye problems on a background of MONOCULAR DIPLOPIA (double vision in only 1 eye) and SCINTILLATING SCOTOMA that appears right sided (when left eye is closed).....is rather difficult to reconcile purely on a NEUROLOGICAL BASIS.
Monocular diplopia is especially difficult to explain and in fact, we teach our residents that if a patient complains of double vision in 1 eye (which has been corroborated through proper confrontational testing) that there is about a 99.9% chance of there be a structural lesion within the globe itself and often times it is in the retina or the optic nerve head. Diplopia in only 1 eye simply has no Central Nervous System (CNS- neurological) explanation except when possibly consideration some wild variation of a zebra disease (i.e. RARE). A search of the literature will literally show you the following causes of such double vision:
refractive errors, corneal disease (e.g., irregular astigmatism), iris lesions, cataracts, and macular disease.
Primary or secondary visual cortical diseases can be rarely associated with monocular diplopia or even MORE THAN 2 IMAGES (cerebral polyopia) but we are probably talking about a COUNTABLE # of cases described in the literature. Personally, I've only seen verifiably documented case of monocular diplopia due to CNS in someone with demyelinating disease where white matter lesions were so strategically placed that you would likely never be able to replicate that patient's condition again. They actually converted from a diplopic condition to XXXXXXX blurriness after about 6 months on a background of OPTIC NEURITIS....so was the diplopia just a prelude to something else down the road? Hard to say.....
But now, here is the interesting part of your story....SUPPORT for an underlying CNS cause to this problem lies in the fact that the diplopia only seems to exist with the left eye CLOSED or obstructed by a prism. When I test my patients for this sort of problem I prefer they not CLOSE the good eye simply sometimes you can't tell whether just the act of closing the eye itself may be causing some aberration of visual perception in the fellow eye....some people really love to SCRUNCH that good eye closed and that could alter all sorts of muscle activity on the "bad side"....make sense?
And so, if the RIGHT EYE really had some type of structural or pathophysiological problem that was OUTSIDE THE CNS proper.....then, I'd expect you to be telling me that even with the LEFT eye open....you would still be experiencing some type of diplopic vision.
So now we come to what rare birds in the CNS can cause diplopic vision of a monocular type and the answer is....RETINAL MIGRAINES (with or without severe headaches). And the support for this diagnosis may be from your complaints of scintillating scotoma or phosphenes as I commonly refer to them in my headache patients. Retinal migraines can come with or without the killer headache and I'm going to assume you don't really have a headache or I'm sure you would've said something to that effect.
However, let it be known that RETINAL MIGRAINES that can have as a typical feature UNILATERAL PHOSPHOGENIC ACTIVITY (scintillating scotoma) as well as MONOCULAR DIPLOPIA still are usually found to have some type of odd or rare intraocular or periocular pathology...retinal disease for example (retinitis pigementosa....I've seen one case of that so far when a headache patient once came to me with similar complaint)....however, that is usually easy to pickup on fundoscopy when one knows what they're looking at and so I find it hard to believe that 4 ocular specialists would miss it...even though it is a rare bird diagnosis.
You say that an MRI was performed....was it done with GADOLINIUM CONTRAST and was it done with FINE CUTS THROUGH THE OTPIC NERVES up to the CHIASM? That is how I would typically order the MRI scan on someone such as yourself if I were confronted with the ocular symptoms and an ALL CLEAR from my ophtho colleagues.
I would also make sure you got VISUAL EVOKED POTENTIALS (VEP) since that test is sensitive (though not specific for location and prone to variability and error for many reasons...but it's still a very good test to verify an INTACT VISUAL PATHWAY SYSTEM) for optic nerve transmission failure which could be due to any number of system failures from the time light HITS the eye to when it is processed in the occipital.
Once again, relying on the fact that you've had at least 3-4 funduscopic evaluations (perhaps even loaded up with a few liters of FLUORESCEIN dye! LOL), dilated eye exams, perimetry testing, etc. and nothing seems to be turning up then, I think the clinical utility of a VEP would be to demonstrate NORMAL RESPONSES.....yes, you heard me correctly. I'd really be looking for the test in this case to be NORMAL which would tell me the visual pathways are not to blame for your symptoms. Unfortunately, it doesn't tell me what is the problem and sort of throws the ball back into the ophthalmologist's court.
A more sensitive type of VEP test is available called the MULTIFOCAL VEP which can discern more precise topographic abnormalities in the visual pathways that are diseased or abnormal than the standard VEP....and perhaps that would be something to consider.
Therefore, and to wrap this XXXXXXX treatise up....I might approach you in the following way with your symptoms:
1. MRI of the head with gadolinium contrast with OPTIC NERVE protocol as described above
2. VEP or mfVEP testing (goal is to see if the testing is NORMAL). Of course, if abnormal, more assessment required.
3. Consideration of oddball things such as RETINAL MIGRAINES
If I've provided useful or helpful information could you do me a HUGE favor by CLOSING THE QUERY and taking a moment to provide a few kind words of feedback, perhaps even stamping the consult with a 5 STAR rating if you feel so inclined?
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in being kept in the loop with how things progress so please drop me a line whenever you seem to be turning the corner or if you end up getting some testing done. I'm happy to give you opinions on those issues as well.
This query has utilized a total of 60 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Retinal migraine can be with or WITHOUT headache
Detailed Answer:
Good evening to a former resident of Montreal.
I was looking at the map trying to figure out if I could recognize the part of Montreal you were in but unfortunately I could not see anything terribly familiar. We were there in 1967 for EXPO 67 when I got lost in La Ronde....that I clearly remember! And we lived in a set of large apartment buildings on DeCarrie Blvd in the same year they opened the subway system...Our station was ATWATER.....I got lost on that thing too which drove my parents nuts! HAHA.... decades later, a fellow resident of that beautiful city I loved while we were there.
Let's take a look at a couple of things that I need to make assumptions on right away because of what you said on your multiple visits to a variety of doctors. You say you've been to multiple optometrists AND ophthalmologists who can't find anything really STRUCTURALLY WRONG with the eye or the periorbital contents....and I'll have to take that as a GIVEN though the phenomenon of the right eye problems on a background of MONOCULAR DIPLOPIA (double vision in only 1 eye) and SCINTILLATING SCOTOMA that appears right sided (when left eye is closed).....is rather difficult to reconcile purely on a NEUROLOGICAL BASIS.
Monocular diplopia is especially difficult to explain and in fact, we teach our residents that if a patient complains of double vision in 1 eye (which has been corroborated through proper confrontational testing) that there is about a 99.9% chance of there be a structural lesion within the globe itself and often times it is in the retina or the optic nerve head. Diplopia in only 1 eye simply has no Central Nervous System (CNS- neurological) explanation except when possibly consideration some wild variation of a zebra disease (i.e. RARE). A search of the literature will literally show you the following causes of such double vision:
refractive errors, corneal disease (e.g., irregular astigmatism), iris lesions, cataracts, and macular disease.
Primary or secondary visual cortical diseases can be rarely associated with monocular diplopia or even MORE THAN 2 IMAGES (cerebral polyopia) but we are probably talking about a COUNTABLE # of cases described in the literature. Personally, I've only seen verifiably documented case of monocular diplopia due to CNS in someone with demyelinating disease where white matter lesions were so strategically placed that you would likely never be able to replicate that patient's condition again. They actually converted from a diplopic condition to XXXXXXX blurriness after about 6 months on a background of OPTIC NEURITIS....so was the diplopia just a prelude to something else down the road? Hard to say.....
But now, here is the interesting part of your story....SUPPORT for an underlying CNS cause to this problem lies in the fact that the diplopia only seems to exist with the left eye CLOSED or obstructed by a prism. When I test my patients for this sort of problem I prefer they not CLOSE the good eye simply sometimes you can't tell whether just the act of closing the eye itself may be causing some aberration of visual perception in the fellow eye....some people really love to SCRUNCH that good eye closed and that could alter all sorts of muscle activity on the "bad side"....make sense?
And so, if the RIGHT EYE really had some type of structural or pathophysiological problem that was OUTSIDE THE CNS proper.....then, I'd expect you to be telling me that even with the LEFT eye open....you would still be experiencing some type of diplopic vision.
So now we come to what rare birds in the CNS can cause diplopic vision of a monocular type and the answer is....RETINAL MIGRAINES (with or without severe headaches). And the support for this diagnosis may be from your complaints of scintillating scotoma or phosphenes as I commonly refer to them in my headache patients. Retinal migraines can come with or without the killer headache and I'm going to assume you don't really have a headache or I'm sure you would've said something to that effect.
However, let it be known that RETINAL MIGRAINES that can have as a typical feature UNILATERAL PHOSPHOGENIC ACTIVITY (scintillating scotoma) as well as MONOCULAR DIPLOPIA still are usually found to have some type of odd or rare intraocular or periocular pathology...retinal disease for example (retinitis pigementosa....I've seen one case of that so far when a headache patient once came to me with similar complaint)....however, that is usually easy to pickup on fundoscopy when one knows what they're looking at and so I find it hard to believe that 4 ocular specialists would miss it...even though it is a rare bird diagnosis.
You say that an MRI was performed....was it done with GADOLINIUM CONTRAST and was it done with FINE CUTS THROUGH THE OTPIC NERVES up to the CHIASM? That is how I would typically order the MRI scan on someone such as yourself if I were confronted with the ocular symptoms and an ALL CLEAR from my ophtho colleagues.
I would also make sure you got VISUAL EVOKED POTENTIALS (VEP) since that test is sensitive (though not specific for location and prone to variability and error for many reasons...but it's still a very good test to verify an INTACT VISUAL PATHWAY SYSTEM) for optic nerve transmission failure which could be due to any number of system failures from the time light HITS the eye to when it is processed in the occipital.
Once again, relying on the fact that you've had at least 3-4 funduscopic evaluations (perhaps even loaded up with a few liters of FLUORESCEIN dye! LOL), dilated eye exams, perimetry testing, etc. and nothing seems to be turning up then, I think the clinical utility of a VEP would be to demonstrate NORMAL RESPONSES.....yes, you heard me correctly. I'd really be looking for the test in this case to be NORMAL which would tell me the visual pathways are not to blame for your symptoms. Unfortunately, it doesn't tell me what is the problem and sort of throws the ball back into the ophthalmologist's court.
A more sensitive type of VEP test is available called the MULTIFOCAL VEP which can discern more precise topographic abnormalities in the visual pathways that are diseased or abnormal than the standard VEP....and perhaps that would be something to consider.
Therefore, and to wrap this XXXXXXX treatise up....I might approach you in the following way with your symptoms:
1. MRI of the head with gadolinium contrast with OPTIC NERVE protocol as described above
2. VEP or mfVEP testing (goal is to see if the testing is NORMAL). Of course, if abnormal, more assessment required.
3. Consideration of oddball things such as RETINAL MIGRAINES
If I've provided useful or helpful information could you do me a HUGE favor by CLOSING THE QUERY and taking a moment to provide a few kind words of feedback, perhaps even stamping the consult with a 5 STAR rating if you feel so inclined?
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in being kept in the loop with how things progress so please drop me a line whenever you seem to be turning the corner or if you end up getting some testing done. I'm happy to give you opinions on those issues as well.
This query has utilized a total of 60 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Fascinating that you mention white matter lesions. The neuro-ophthalmologist mentioned that I had “slight abnormalities in the white matter of your brain” after the MRI.
He said it wasn’t to be concerned about and didn’t elaborate further.
Are you by any chance familiar with the uncommon diagnoses of “visual snow” and “persistent aura without infarction”?
He said it wasn’t to be concerned about and didn’t elaborate further.
Are you by any chance familiar with the uncommon diagnoses of “visual snow” and “persistent aura without infarction”?
Fascinating that you mention white matter lesions. The neuro-ophthalmologist mentioned that I had “slight abnormalities in the white matter of your brain” after the MRI.
He said it wasn’t to be concerned about and didn’t elaborate further.
Are you by any chance familiar with the uncommon diagnoses of “visual snow” and “persistent aura without infarction”?
He said it wasn’t to be concerned about and didn’t elaborate further.
Are you by any chance familiar with the uncommon diagnoses of “visual snow” and “persistent aura without infarction”?
Brief Answer:
White matter lesions that are insignificant
Detailed Answer:
Good morning.
Thank you for your return response. So, if the neuro-ophthalmologist wasn't impressed with the white matter lesions then, I would say that's reliable news. I'm imagining then, that the radiologist reading the study also didn't make a big deal out of them and simply made the call of their presence which is common for these sorts of reads. White matter degeneration in the brain is very common in people just on the basis of aging over 35 years let alone having other risk factors that people can have such as hypertension, diabetes, smoking habits, high cholesterol, and even more risk factors that have been found to be in association with this condition. What you wouldn't want to have would be an unusual burden or PLAQUES of white matter degeneration because as you probably know from your own readins that would signify a horse of a different color.
I guess I'm still curious though on how the diagnosis of PSEUDOTUMOR was made on you and was the MRI done with contrast or without since sometimes those can come out differently even in people who have insignificant white matter disease? And I also suppose the neuro-ophthalmologist didn't think your brain imaging any UBO's (Unidentified Bright Objects), right? Those again are thought to be spots of more high intensity magnitude that SHINE through an MRI a bit more robustly than just plain old white matter degeneration. They are correlated with a lot of different things and are nonspecific but if someone has migraine headaches and UBO's and nothing else going on then, that is taken usually as a correlative piece of imaging information to support the diagnosis of the headache. We don't treat them...we don't follow them although many of them change size over time or even disappear.
With respect to visual snow and PMA....yes, I'm familiar with those entities but although patients with migraine headaches can certainly refer these visual phenomenon....sometimes it's difficult to separate the aura of their headache from the "static".....I find it useful in such cases to have the patients keep strict diaries of their HEADACHES and visual symptoms because often times the patient knows which is the SNOW and which is the AURA. I'll even have them draw pictures.
There is also something called ACEPHALGIC MIGRAINE which throws even one more confusing wrench into the works because in this condition the patient clearly has AURA (usually visual) but for all the GLITTER or LIGHTNING BUGS they can appreciate....and some times TINNITUS and sometimes VERTIGO gets thrown in....there's never a headache and usually these are very episodic lasting only minutes at a times or less making it difficult to treat with anything but prophylactic medications such as calcium channel blockers, topiramate, or anti-epileptic drugs. Funnily enough I've had very good luck treating these crazy types of headache symptoms with PROPRANOLOL.
As far as the PMA is concerned....I've also patients with that condition with the difference being the duration of episodes which are much longer (days to weeks to months) and some patients even report symptoms being ALWAYS present but that they just get worse or better as the day goes on and never seem to completely go away. Also, with PMA descriptions of neurological phenomenon such as feelings of pins and needles and even motor clumsiness affecting hands, fingers, and feet can occur transiently and go away. And of course, there is no long term complication such as stroke or any type of detectable ischemia in the brain though circulatory patterns seem to shift when measured by elegant methods in these patients.
Once again, if I've provided good information on your query I'd be very grateful if you'd CLOSE THE QUERY and take a moment to provide a few kind words of feedback, and even giving the response a 5 STAR rating.
Please drop me a line whenever you get any additional testing done or if there is a suggestion at some treatment for your condition. I'm happy to give you opinions on those issues as well.
This query has utilized a total of 113 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
White matter lesions that are insignificant
Detailed Answer:
Good morning.
Thank you for your return response. So, if the neuro-ophthalmologist wasn't impressed with the white matter lesions then, I would say that's reliable news. I'm imagining then, that the radiologist reading the study also didn't make a big deal out of them and simply made the call of their presence which is common for these sorts of reads. White matter degeneration in the brain is very common in people just on the basis of aging over 35 years let alone having other risk factors that people can have such as hypertension, diabetes, smoking habits, high cholesterol, and even more risk factors that have been found to be in association with this condition. What you wouldn't want to have would be an unusual burden or PLAQUES of white matter degeneration because as you probably know from your own readins that would signify a horse of a different color.
I guess I'm still curious though on how the diagnosis of PSEUDOTUMOR was made on you and was the MRI done with contrast or without since sometimes those can come out differently even in people who have insignificant white matter disease? And I also suppose the neuro-ophthalmologist didn't think your brain imaging any UBO's (Unidentified Bright Objects), right? Those again are thought to be spots of more high intensity magnitude that SHINE through an MRI a bit more robustly than just plain old white matter degeneration. They are correlated with a lot of different things and are nonspecific but if someone has migraine headaches and UBO's and nothing else going on then, that is taken usually as a correlative piece of imaging information to support the diagnosis of the headache. We don't treat them...we don't follow them although many of them change size over time or even disappear.
With respect to visual snow and PMA....yes, I'm familiar with those entities but although patients with migraine headaches can certainly refer these visual phenomenon....sometimes it's difficult to separate the aura of their headache from the "static".....I find it useful in such cases to have the patients keep strict diaries of their HEADACHES and visual symptoms because often times the patient knows which is the SNOW and which is the AURA. I'll even have them draw pictures.
There is also something called ACEPHALGIC MIGRAINE which throws even one more confusing wrench into the works because in this condition the patient clearly has AURA (usually visual) but for all the GLITTER or LIGHTNING BUGS they can appreciate....and some times TINNITUS and sometimes VERTIGO gets thrown in....there's never a headache and usually these are very episodic lasting only minutes at a times or less making it difficult to treat with anything but prophylactic medications such as calcium channel blockers, topiramate, or anti-epileptic drugs. Funnily enough I've had very good luck treating these crazy types of headache symptoms with PROPRANOLOL.
As far as the PMA is concerned....I've also patients with that condition with the difference being the duration of episodes which are much longer (days to weeks to months) and some patients even report symptoms being ALWAYS present but that they just get worse or better as the day goes on and never seem to completely go away. Also, with PMA descriptions of neurological phenomenon such as feelings of pins and needles and even motor clumsiness affecting hands, fingers, and feet can occur transiently and go away. And of course, there is no long term complication such as stroke or any type of detectable ischemia in the brain though circulatory patterns seem to shift when measured by elegant methods in these patients.
Once again, if I've provided good information on your query I'd be very grateful if you'd CLOSE THE QUERY and take a moment to provide a few kind words of feedback, and even giving the response a 5 STAR rating.
Please drop me a line whenever you get any additional testing done or if there is a suggestion at some treatment for your condition. I'm happy to give you opinions on those issues as well.
This query has utilized a total of 113 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Brief Answer:
White matter lesions that are insignificant
Detailed Answer:
Good morning.
Thank you for your return response. So, if the neuro-ophthalmologist wasn't impressed with the white matter lesions then, I would say that's reliable news. I'm imagining then, that the radiologist reading the study also didn't make a big deal out of them and simply made the call of their presence which is common for these sorts of reads. White matter degeneration in the brain is very common in people just on the basis of aging over 35 years let alone having other risk factors that people can have such as hypertension, diabetes, smoking habits, high cholesterol, and even more risk factors that have been found to be in association with this condition. What you wouldn't want to have would be an unusual burden or PLAQUES of white matter degeneration because as you probably know from your own readins that would signify a horse of a different color.
I guess I'm still curious though on how the diagnosis of PSEUDOTUMOR was made on you and was the MRI done with contrast or without since sometimes those can come out differently even in people who have insignificant white matter disease? And I also suppose the neuro-ophthalmologist didn't think your brain imaging any UBO's (Unidentified Bright Objects), right? Those again are thought to be spots of more high intensity magnitude that SHINE through an MRI a bit more robustly than just plain old white matter degeneration. They are correlated with a lot of different things and are nonspecific but if someone has migraine headaches and UBO's and nothing else going on then, that is taken usually as a correlative piece of imaging information to support the diagnosis of the headache. We don't treat them...we don't follow them although many of them change size over time or even disappear.
With respect to visual snow and PMA....yes, I'm familiar with those entities but although patients with migraine headaches can certainly refer these visual phenomenon....sometimes it's difficult to separate the aura of their headache from the "static".....I find it useful in such cases to have the patients keep strict diaries of their HEADACHES and visual symptoms because often times the patient knows which is the SNOW and which is the AURA. I'll even have them draw pictures.
There is also something called ACEPHALGIC MIGRAINE which throws even one more confusing wrench into the works because in this condition the patient clearly has AURA (usually visual) but for all the GLITTER or LIGHTNING BUGS they can appreciate....and some times TINNITUS and sometimes VERTIGO gets thrown in....there's never a headache and usually these are very episodic lasting only minutes at a times or less making it difficult to treat with anything but prophylactic medications such as calcium channel blockers, topiramate, or anti-epileptic drugs. Funnily enough I've had very good luck treating these crazy types of headache symptoms with PROPRANOLOL.
As far as the PMA is concerned....I've also patients with that condition with the difference being the duration of episodes which are much longer (days to weeks to months) and some patients even report symptoms being ALWAYS present but that they just get worse or better as the day goes on and never seem to completely go away. Also, with PMA descriptions of neurological phenomenon such as feelings of pins and needles and even motor clumsiness affecting hands, fingers, and feet can occur transiently and go away. And of course, there is no long term complication such as stroke or any type of detectable ischemia in the brain though circulatory patterns seem to shift when measured by elegant methods in these patients.
Once again, if I've provided good information on your query I'd be very grateful if you'd CLOSE THE QUERY and take a moment to provide a few kind words of feedback, and even giving the response a 5 STAR rating.
Please drop me a line whenever you get any additional testing done or if there is a suggestion at some treatment for your condition. I'm happy to give you opinions on those issues as well.
This query has utilized a total of 113 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
White matter lesions that are insignificant
Detailed Answer:
Good morning.
Thank you for your return response. So, if the neuro-ophthalmologist wasn't impressed with the white matter lesions then, I would say that's reliable news. I'm imagining then, that the radiologist reading the study also didn't make a big deal out of them and simply made the call of their presence which is common for these sorts of reads. White matter degeneration in the brain is very common in people just on the basis of aging over 35 years let alone having other risk factors that people can have such as hypertension, diabetes, smoking habits, high cholesterol, and even more risk factors that have been found to be in association with this condition. What you wouldn't want to have would be an unusual burden or PLAQUES of white matter degeneration because as you probably know from your own readins that would signify a horse of a different color.
I guess I'm still curious though on how the diagnosis of PSEUDOTUMOR was made on you and was the MRI done with contrast or without since sometimes those can come out differently even in people who have insignificant white matter disease? And I also suppose the neuro-ophthalmologist didn't think your brain imaging any UBO's (Unidentified Bright Objects), right? Those again are thought to be spots of more high intensity magnitude that SHINE through an MRI a bit more robustly than just plain old white matter degeneration. They are correlated with a lot of different things and are nonspecific but if someone has migraine headaches and UBO's and nothing else going on then, that is taken usually as a correlative piece of imaging information to support the diagnosis of the headache. We don't treat them...we don't follow them although many of them change size over time or even disappear.
With respect to visual snow and PMA....yes, I'm familiar with those entities but although patients with migraine headaches can certainly refer these visual phenomenon....sometimes it's difficult to separate the aura of their headache from the "static".....I find it useful in such cases to have the patients keep strict diaries of their HEADACHES and visual symptoms because often times the patient knows which is the SNOW and which is the AURA. I'll even have them draw pictures.
There is also something called ACEPHALGIC MIGRAINE which throws even one more confusing wrench into the works because in this condition the patient clearly has AURA (usually visual) but for all the GLITTER or LIGHTNING BUGS they can appreciate....and some times TINNITUS and sometimes VERTIGO gets thrown in....there's never a headache and usually these are very episodic lasting only minutes at a times or less making it difficult to treat with anything but prophylactic medications such as calcium channel blockers, topiramate, or anti-epileptic drugs. Funnily enough I've had very good luck treating these crazy types of headache symptoms with PROPRANOLOL.
As far as the PMA is concerned....I've also patients with that condition with the difference being the duration of episodes which are much longer (days to weeks to months) and some patients even report symptoms being ALWAYS present but that they just get worse or better as the day goes on and never seem to completely go away. Also, with PMA descriptions of neurological phenomenon such as feelings of pins and needles and even motor clumsiness affecting hands, fingers, and feet can occur transiently and go away. And of course, there is no long term complication such as stroke or any type of detectable ischemia in the brain though circulatory patterns seem to shift when measured by elegant methods in these patients.
Once again, if I've provided good information on your query I'd be very grateful if you'd CLOSE THE QUERY and take a moment to provide a few kind words of feedback, and even giving the response a 5 STAR rating.
Please drop me a line whenever you get any additional testing done or if there is a suggestion at some treatment for your condition. I'm happy to give you opinions on those issues as well.
This query has utilized a total of 113 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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