When people come in with complaints of “double vision”, I find it is almost always bull. It rarely really is true diplopia - it is 99% of the time “blurred” vision or something else nonspecific. True double vision is worrisome. It implies a problem with the muscles that move the eye - causing one (or both) to not move with the other - resulting in two images. It resolves by covering one eye, and in some cases, certain movements of the head.
The other day there was teenager who came in with this complaint and as soon as I saw him sitting there, I knew he had something “real” going on. He had his head tilted slightly to the left - and told me the diplopia improved with that. Further history elicited other worrisome findings of hypogeusia (diminished sense of taste), coordination problems, and intermittent facial numbness on the right side. All over the last week. He came in that particular day because he developed a headache and some vomiting.
His exam elicited a rare finding (at least in my practise but probably a daily occurrence in Dr Grumpy’s office), Hypertropia of the right eye - more exaggerated when the head was tilted to the right. This means he had Trochlear Nerve Palsy (IV cranial nerve) - something I have seen only once before. This nerve is one of several that controls the movements of your eyes and when it is either compressed or otherwise affected, the eye will drift upwards, given you double vision. Generally things that cause this are BAD (not always but it ain’t never good). Think brain tumours, aneurysms, other masses, demyelinating disease (like MS), lymphoma, to name a few. The rest of his exam was full of abnormalities too like hyperreflexia (reflexes being too brisk), numbness, and trouble walking and coordinating his hands.
He got a CT. Bad. All sorts of areas of abnormality. I broke my “no MRI’s in the ER” rule because I was very worried about him and knew that for him to get an outpatient MRI to rule something really bad out might take weeks of fussing with insurance companies. Fortunately for him, he did not have cancer. Unfortunately though, it looks like he most likely has bad Multiple Sclerosis. His brain lit up like a Christmas Tree. He got admitted for further workup and to start steroids. Telling the patient and family the probable diagnosis was pretty hard. Talk about a blindside. I really hope he improves.
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Interesting case. Yeah, onset that young can be tough. But the heavy hitters (Tysabri and Novantrone) are there, and several new agents (not on market yet) are looking impressive.
What US President had a congenital head tilt from a IV palsy: Buchanan. His opponents used negative campaigning to claim it was tilted from breaking his neck in an attempted suicide by hanging. Showing that politics has always been dirty.
Ouch. Not good news. I began having double vision problems about a year ago — found out I had MG — but my doctors were all more panicked than I was thinking that I probably had a brain tumor. Double vision is never a good, or fun, thing.
Poor kid. I hope they can do something for him.
awww The poor kid! my hubby has MS, just diagnosed this past sept. he is on betaserum, and all greens diet! he has about 8 lesions on his brain, and only one of them is right next to his spinalcord, which causes lower back pain, leg pain, arm pain.His lesions are white, for now, we are hoping that with the medication and his diet change will stop or slow the progression, I feel bad for this teenager on your post, he is soo young, I hope he recovers from this!
Why don’t you do MRIs in the ER? Just interested in your thinking there. Very sad case.
Any theory on why MS has a higher incidence in the Pacific Northwest and Epstein Barr Virus?
I feel your pain. Once had a young girl that came in with ‘trouble with her contacts’. On assessment, her eyes were all over the place, clearly a nerve issue. CT showed a big ole’ nasty glioblastoma. Admitting doc gave her 3 months. Several years later, had a teen come in with sudden onset loss of vision in one eye. She acted like it didn’t really bother her, like her parents made her come in with a runny nose. However, with my other bad experience still painful, I was quite upset. We transferred her, I asked the parents to please call me and let me know what happened. No need-the doc we transferred her to called within an hour-she was faking. I could have strangled her. What a waste of time, money and ‘neggie’ emotions.