CASE OF THE MONTH
Sudden vision loss in a child Elana A. Min, MMS, PA-C
CASE A 7-year-old girl was seen in the ED due to a sudden loss of vision while reading at school. She had described an onset of transient “rainbows,” “sparkles,” and occasional blurry vision for the past 3 days. She first reported seeing rainbows around objects during recess at school and now says she sees them around bright lights during the day and around her nightlight at night. She also reported increased difficulty reading due to blurry vision. She denies headache, floaters, eye pain, nausea, or vomiting. Her past medical history is remarkable for infantile eczema. Her last eye examination was 1 year ago and normal. She fell down a waterslide 2 months ago and had stitches placed behind her right ear, but had no loss of consciousness with the fall. She was a full-term neonate, born via normal spontaneous vaginal delivery; she had breastfeeding jaundice. Her family history is noncontributory. She lives with her parents and two siblings in a nonsmoking household, is up-to-date with her immunizations, and receives regular annual pediatric examinations. She is in the 75th percentile for both height and weight. The initial examination revealed stable vital signs and visual acuity of 20/30 in both eyes. Her pupils were 4 mm, round, and reactive to light. Extraocular movements were intact, and visual fields were full to confrontation. Fundoscopic examination revealed no papilledema or gross retinal changes, and a normal optic cup/disk ratio. She had no focal neurologic deficits on examination. An EEG revealed no acute seizure activity, and a brain MRI was negative for lesions. A complete blood cell count, urinalysis, comprehensive metabolic profile, and glucose were all within normal limits. WHAT IS YOUR DIAGNOSIS? • brain tumor • diabetic retinopathy Elana A. Min is an assistant professor and director of academic education for the PA program at Rush University Medical Center in Chicago, Ill. The author has indicated no relationships to disclose relating to the content of this article. Adrian Banning, MMS, PA-C, department editor DOI: 10.1097/01.JAA.0000442709.20256.66 Copyright © 2014 American Academy of Physician Assistants
52
www.JAAPA.com
• • • •
epilepsy ophthalmic migraine psychiatric pathology retinitis pigmentosa
DISCUSSION The patient has ophthalmic migraines (also known as ocular, visual, or retinal migraines) with a possible association to her previous concussion. Ophthalmic migraines are a variant of general migraines and are more prevalent in female than in male patients (16 to 1).1 These migraines may or may not present with traditional headache symptoms with variable symptom patterns. Although ophthalmic migraines tend to present with a monocular loss of vision, visual disturbances such as loss, blurring, scotomas, and dimming can occur bilaterally.2 Ophthalmic migraine is often a diagnosis of exclusion, as in the case of this patient, and practitioners need to have a high index of suspicion for this diagnosis when evaluating visual disturbances in children.1 Other causes of sudden changes in vision or loss of vision in children include refractive error, retinal vascular occlusion, retinal detachment, retinal hemorrhage, epileptic seizure, and medically unexplained visual loss. In children presenting with sudden vision loss, benign causes such as refractive error or migraines are the most common. However, more serious causes (such as occlusions or hemorrhage) can be associated with trauma, leukemia, and other blood dyscrasias.3 Volume 27 • Number 2 • February 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Sudden vision loss in a child
Key points Ophthalmic migraines are more common in female than male patients, may not present with traditional headache symptoms, and may follow different patterns than traditional migraines. Loss of vision may be monocular or binocular. In children with acute vision loss, benign causes such as migraine are most common; serious causes such as occlusions and hemorrhage may be associated with trauma or blood dyscrasias.
No protocol exists for managing ophthalmic migraines. The mainstay of treatment is avoiding potential triggers and providing reassurance to the parents.1 The clinical course of migraines in children can be influenced by stress, sleep deprivation, and fluctuating hormones. In a study specifically following children with migraines, 62% were migraine-free for at least 2 years during puberty and young adulthood, with 33% having a recurrence of migraines in adulthood, after an average of 6 migraine-free years. Twentytwo percent of the children never had a migraine-free year.4
In the case of this patient, these visual disturbances may have been related to her previous head trauma. She was treated with observation and preventive measures, including sunglasses to cut down glare during exposure to sunlight and fluorescent lights, and a reduction in reading to reduce eye fatigue. These measures dramatically reduce the frequency and severity of the visual disturbances. The episodes gradually decreased, with complete resolution 4 weeks later. A year later, the patient has not experienced any further visual disturbances. Because the precise cause of her ophthalmic migraines was not known, her prognosis is favorable if she remains migraine-free through puberty. JAAPA REFERENCES 1. Grosberg BM, Solomon S, Lipton RB. Retinal migraine. Curr Pain Headache Rep. 2005;9(4):268-271. 2. Pradhan S, Chung SM. Retinal, ophthalmic, or ocular migraine. Curr Neurol Neurosci Rep. 2004;4(5):391-397. 3. Tatham AJ. Transient loss of vision. http://emedicine.medscape. com/article/1435495-overview. Accessed August 18, 2013. 4. Bille B. A 40-year follow-up of school children with migraine. Cephalalgia. 1997;17(4):488-491
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.JAAPA.com
53
Sudden vision loss in a child Elana A. Min, MMS, PA-C
CASE A 7-year-old girl was seen in the ED due to a sudden loss of vision while reading at school. She had described an onset of transient “rainbows,” “sparkles,” and occasional blurry vision for the past 3 days. She first reported seeing rainbows around objects during recess at school and now says she sees them around bright lights during the day and around her nightlight at night. She also reported increased difficulty reading due to blurry vision. She denies headache, floaters, eye pain, nausea, or vomiting. Her past medical history is remarkable for infantile eczema. Her last eye examination was 1 year ago and normal. She fell down a waterslide 2 months ago and had stitches placed behind her right ear, but had no loss of consciousness with the fall. She was a full-term neonate, born via normal spontaneous vaginal delivery; she had breastfeeding jaundice. Her family history is noncontributory. She lives with her parents and two siblings in a nonsmoking household, is up-to-date with her immunizations, and receives regular annual pediatric examinations. She is in the 75th percentile for both height and weight. The initial examination revealed stable vital signs and visual acuity of 20/30 in both eyes. Her pupils were 4 mm, round, and reactive to light. Extraocular movements were intact, and visual fields were full to confrontation. Fundoscopic examination revealed no papilledema or gross retinal changes, and a normal optic cup/disk ratio. She had no focal neurologic deficits on examination. An EEG revealed no acute seizure activity, and a brain MRI was negative for lesions. A complete blood cell count, urinalysis, comprehensive metabolic profile, and glucose were all within normal limits. WHAT IS YOUR DIAGNOSIS? • brain tumor • diabetic retinopathy Elana A. Min is an assistant professor and director of academic education for the PA program at Rush University Medical Center in Chicago, Ill. The author has indicated no relationships to disclose relating to the content of this article. Adrian Banning, MMS, PA-C, department editor DOI: 10.1097/01.JAA.0000442709.20256.66 Copyright © 2014 American Academy of Physician Assistants
52
www.JAAPA.com
• • • •
epilepsy ophthalmic migraine psychiatric pathology retinitis pigmentosa
DISCUSSION The patient has ophthalmic migraines (also known as ocular, visual, or retinal migraines) with a possible association to her previous concussion. Ophthalmic migraines are a variant of general migraines and are more prevalent in female than in male patients (16 to 1).1 These migraines may or may not present with traditional headache symptoms with variable symptom patterns. Although ophthalmic migraines tend to present with a monocular loss of vision, visual disturbances such as loss, blurring, scotomas, and dimming can occur bilaterally.2 Ophthalmic migraine is often a diagnosis of exclusion, as in the case of this patient, and practitioners need to have a high index of suspicion for this diagnosis when evaluating visual disturbances in children.1 Other causes of sudden changes in vision or loss of vision in children include refractive error, retinal vascular occlusion, retinal detachment, retinal hemorrhage, epileptic seizure, and medically unexplained visual loss. In children presenting with sudden vision loss, benign causes such as refractive error or migraines are the most common. However, more serious causes (such as occlusions or hemorrhage) can be associated with trauma, leukemia, and other blood dyscrasias.3 Volume 27 • Number 2 • February 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Sudden vision loss in a child
Key points Ophthalmic migraines are more common in female than male patients, may not present with traditional headache symptoms, and may follow different patterns than traditional migraines. Loss of vision may be monocular or binocular. In children with acute vision loss, benign causes such as migraine are most common; serious causes such as occlusions and hemorrhage may be associated with trauma or blood dyscrasias.
No protocol exists for managing ophthalmic migraines. The mainstay of treatment is avoiding potential triggers and providing reassurance to the parents.1 The clinical course of migraines in children can be influenced by stress, sleep deprivation, and fluctuating hormones. In a study specifically following children with migraines, 62% were migraine-free for at least 2 years during puberty and young adulthood, with 33% having a recurrence of migraines in adulthood, after an average of 6 migraine-free years. Twentytwo percent of the children never had a migraine-free year.4
In the case of this patient, these visual disturbances may have been related to her previous head trauma. She was treated with observation and preventive measures, including sunglasses to cut down glare during exposure to sunlight and fluorescent lights, and a reduction in reading to reduce eye fatigue. These measures dramatically reduce the frequency and severity of the visual disturbances. The episodes gradually decreased, with complete resolution 4 weeks later. A year later, the patient has not experienced any further visual disturbances. Because the precise cause of her ophthalmic migraines was not known, her prognosis is favorable if she remains migraine-free through puberty. JAAPA REFERENCES 1. Grosberg BM, Solomon S, Lipton RB. Retinal migraine. Curr Pain Headache Rep. 2005;9(4):268-271. 2. Pradhan S, Chung SM. Retinal, ophthalmic, or ocular migraine. Curr Neurol Neurosci Rep. 2004;4(5):391-397. 3. Tatham AJ. Transient loss of vision. http://emedicine.medscape. com/article/1435495-overview. Accessed August 18, 2013. 4. Bille B. A 40-year follow-up of school children with migraine. Cephalalgia. 1997;17(4):488-491
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.JAAPA.com
53
