53 y/o male pt with CC of "eyes jumping" x 4 years

[ndaisyk]

I am in need of some feedback. Any info you share is greatly appreciated!

S

CC: 53 y/o male pt with CC of "eyes jumping" x 4 years

HPI: My 53 year old male pt presented last month with c/o "eyes jumping." After exploring this symptom, he describes it like he feels his eyes moving back and forth quickly and his vision blurs; this causes dizziness and nausea. There is no associated pain. This can happen with activity, or at rest. During activity, he has to stop what he's doing and drop to one knee or lean against a wall to keep himself from falling over due to dizziness. He states that closing one eye helps him not feel so dizzy, too. Episodes can last anywhere from a few seconds to 10 to 15 minutes. The last episode lasted 20 minutes and was so severe, he had to lie down. The pt states this started 4 years ago, and has increased in frequency to 2 times a month, presently. He reports some episodes of tinnitus which are unrelated to the above scenario. Of note, he does not endorse true vertigo.

 

SHx: mechanic, 30 pack year hx, quit 5 years ago. divorced. Rare ETOH use.

PMH: hyperlipidemia, GERD, seasonal allergies

MEDS: loratadine 10mg qd

Simvastatin 20 mg qd

omeprazole 20 mg qd

Elestat eye drops BID

Fhx: Mom; DMII, DV dz, HTN, COPD

Dad; died of MI at age 64

NO ALLERGIES

ROS: no SOB, chest pain. No hx of migraines or migraine -like headaches. No hx of concussion. No reported hearing loss. No c/o pain.

 

O

PE:

220 lbs 70.5 inches 130/88 HR 82 Temp 97 resp 20 O2 sat 94%

 

skin: without lesions

HEENT

head: normocephalic

eyes: PERRL EOMI without nystagmus

ears: TM intact bilaterally, non-erythematous

nose: nares patent bilaterally, without rhinorrhea

throat/neck: no lymphadenopathy, uvula mid-line

 

lungs: CTAB, without wheeze, crackles

cor: RRR, no murmur

ext: no edema

 

data:

CBC: HCT, MCV, and MCH elevated; 53.3, 96, 32.1, respectively. Remainder nrml

PSA: 2.99

CMP: Glu 113, remainder nrml

A1C:5.8

Cholesterol: Trig-160 TC-203 HDL-45 calc LDL-126 VLDL-32 Chol/HDL ratio-4.51

nrml CT angiogram of the Circle of Willis

CT scan, head: without abnormalities

ophthalmologist consult: dx of ocular migraine

 

A/P: My next idea is to rule out causes of vertigo, even though he doesn't have true vertigo. Also, I am disinclined to endorsing the dx of ocular migraine, as his visual symptoms are bilateral, whereas ocular migraine symptoms are unilateral; I am going to call another ophthalmologist and present this case.

If you've seen this in practice, please share any ideas.

THANKS!!!!

[marilynpac]

I've had ocular migraines and mine started unilateral and went bilateral. My first impression was meniers(sp) disease b/c members of my family have had that with almost the same sx that you describe. Also I've heard of people with hyperlipidemia experience this. Getting another consult is an excellent idea.

[ndaisyk]

Thank you for your response!!!

[jer_sd]

Off the top of my head Nystagmus can indicate vestibular dysfunction did you check Romberg?

[mjohnson3604]

Hi,

 

I have seen patients with sudden onset Nystagmus in practice as an Ophthalmic Technician. Many times there is a neurological underlying cause, but sometimes latent refractive error, trauma, an even stress can have same result. Make sure your consult is with a Neuro Ophthalmologist or Peds/Oculomotor specialist (they can at least relieve the dizzyness with prism or other methods).

 

Good Luck

[bmurphyl512]

Dizziness and tinnitus. How about acoustic nueroma? Just a pre-pa student stab at it.

[bradtPA]

You can try the Dix-Hallpike maneuver, and see if you get a response....