What could be the reason behind blurred vision, double vision, and ocular pain?

Question

Hi doctor,

I have blurred vision, double vision, and ocular pain in the left eye intensified with eyeballs movement. In the left eye, I have exophthalmos and eyelid ptosis. I had the same cohort of symptoms two years ago, and symptoms began and stopped after six months. I did not receive a diagnosis for my problem. An eyelids and upper limbs electromyography excluded myasthenia gravis (together with the blood test). In the past two weeks, I had examination investigations which are brain TC, nerve optic OCT, brain, ocular orbits, and spine MRI, visual field study, visual evoked potentials, neurological exam, ophthalmological exam, hess lancaster test and red desaturation test. Results o brain TC was negative. Ocular orbit MRI (without gadolinium) modest enlargement of both nerve optic sheaths. This scan was performed 3 days after the beginning of the symptoms. Ocular orbits, brain, and spine MRI (with gadolinium): negative, absence of MS lesions. Optic nerve OCT negative. Visual field study was normal. Visual evoked potentials. Left eye P100 = 110 to 125 millisecond, right eye P100 = 106 to 118 millisecond. The neurological exam is negative. opthalmogical exam conjunctival hyperemia, mild pallor in temporal sectors of left eye optic nerve. Red desaturation test positive for the left eye (red color less bright from the left eye than the right one).Hess Lancaster test negative. My general physician cannot understand my symptoms. Which diagnosis could I have? Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

It is very difficult to give you a diagnosis. You are complaining of blurred vision but your ophthalmologic examination is normal except for conjunctival hyperemia and disc pallor. You have double vision, Hess Lancaster tests show that there is no true diplopia. Pain in eye movement along with blurred vision suggests optic neuritis but all your MRI (magnetic resonance imaging), visual fields are normal.so, ruled out. Exophthalmos usually presents with eyelid retraction and thyroid is the main cause in these patients; you do not have lid retraction but you have ptosis. Again difficult to explain. You have exophthalmos but your orbit scans are not explaining its reason. According to me you have little perception of blurred vision, red desaturation test, and temporal disc pallor suggest you had an episode of optic neuritis in the past which is resolved now. So, these symptoms are explained. Now we have to explain exophthalmos with ptosis with all normal scans. I cannot really think of a condition that explains this. I will also discuss this with my colleagues and will search the literature as well. Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

I discussed this with my colleagues but was unable to find a diagnosis for you. However, unilateral proptosis with conjunctival congestion and pain in eye movements can be due to pseudotumor which is one form of inflammation. this usually responds to oral steroids. However, it also does not explain ptosis and normal scans but all other symptoms are explained. You can discuss this condition as a possibility with your treating ophthalmologist. Please do update me in case your ophthalmologist reaches a diagnosis. Thank you.