A 21-Year-Old With Headache and Blurred Vision

Heather R. Miller, OD; Case Series Editor: Jean Marie Pagani, OD


June 13, 2013

Clinical Presentation

A 21-year-old black woman is experiencing headache originating on the right temporal area and radiating to the back of her head. She is 5'1" tall and weighs 245 lb, a gain of 50-60 lb in the past year. The headache, which started 1 week earlier, has been waking her from her sleep. She denies nausea or vomiting. Four days before this visit, she woke up with blurred vision in her right eye. She reports 1 episode of horizontal diplopia and seeing a flash of light in her right eye.

She went to a hospital emergency department 2 days earlier, where she was told that it was a sinus headache, and she was started on a nasal decongestant. This relieved the pain somewhat, but the headache returned as soon as the medication started to wear off. No other neurologic symptoms are reported.

The patient's medical history is remarkable for sinus headaches. However, she feels that her current headache symptoms are not the same as previous sinus headaches. Her current medications include a nasal decongestant and naproxen 500 mg for menstrual cramps. Because the naproxen was providing some relief for her headache, she has been taking it on a regular basis. Her ocular history is unremarkable.

Examination findings included the following:

Best-corrected visual acuity: 20/20-3 OD with reported distortion, and 20/20 OS.

Pupils: equal, round, and reactive, with no afferent pupillary defect.

Color vision: 13/14 plates OD and 14/14 plates OS by the Ishihara test.

Confrontation fields: full to finger count OU; no red or brightness desaturation.

Palpebral apertures: 8 mm OU.

Exophthalmometry with a base of 101 mm; 19 mm OU.

Humphrey visual field testing: nasal defect greater superiorly; OD and OS full.

Slit-lamp biomicroscopic examination: grade 1+ temporal injection OD, with clear cornea, iris, anterior chamber and lenses bilaterally; anterior segment OS normal.

Goldmann applanation tonometry: 28 mm Hg OD and 22 mm Hg OS.

Blood pressure: 160/98 mm Hg right arm sitting.

A dilated fundus examination revealed C/D ratios of 0.3 × 0.3, with a pink and intact neuroretinal rim and no evidence of pallor bilaterally. The right eye showed numerous choroidal folds throughout the entire posterior pole with a raised area temporal to the foveola (Figures 1 and 2). The left eye was unremarkable.

Figure 1. Posterior pole, right eye.

Figure 2. Macula, right eye.

Additional testing was ordered and conducted, including the following:

Complete blood count with differential;

Platelet count;

Erythrocyte sedimentation rate;

C-reactive protein level;

Lyme titer;

Rapid plasma regain;

Fluorescent Treponema pallidum antibodies;

Angiotensin-converting enzyme level;

Antinuclear antibody with reflex titer;

Extractable nuclear antigen panel;

Anti-double-stranded DNA antibodies;

Rheumatoid factor;

Perinuclear antineutrophil cytoplasmic antibodies;

Cytoplasmic antineutrophil cytoplasmic antibodies;

Human leukocyte antigen (HLA) A, B, C typing; and

Purified protein derivative.

Imaging included ultrasonography, MRI, and intravenous fluorescein angiography.