A 42-year-old Native American male presented to our clinic with an increasing headache over the last week. He had difficulty pinpointing the exact location of the pain but noticed a sparkling blue light off to his left side for the last four days. His history was significant for uncontrolled diabetes and hypertension despite being prescribed insulin, lisinopril, and hydrochlorothiazide.
Visual acuity in each eye was 20/20, and extraocular muscles (EOMs), pupils and slit lamp findings were normal. Reduced arcuate fields were noted on his left side. Dilated fundus exam revealed mild non-proliferative diabetic retinopathy. An automated visual field was run (Figures 1 and 2).
Due to the congruent nature of the visual field defect, the patient’s systemic history, and the recent onset of worsening symptoms, we elected to order an MRI with and without contrast to rule out a space-occupying lesion or intracranial bleed. We first ordered BUN/creatinine blood tests, which were normal, then communicated the patient’s history and visual field findings with the consulting radiologist.
The MRI (Figure 3) showed no mass lesion, no evidence of acute hemorrhage, nor any acute intracranial abnormality or abnormal areas of enhancement. Although negative, the MRI was useful as a diagnosis of exclusion. We made a diagnosis of intractable migraine secondary to uncontrolled cardiovascular disease and worked with patient’s primary-care provider for blood sugar, blood pressure, and pain management.
A 35-year-old, obese white female reported to our clinic with complaints of decreased vision in her left eye with mild pain behind and around the eye for the last two days. The patient reported no health problems or current medications but did state that she had been fairly fatigued recently.
Best corrected acuities were 20/20 OD and 20/30 OS. EOMs, pupils, confrontational fields, and slit lamp examination were normal. Dilated fundus exam revealed a normal optic disc in the right eye and a mildly swollen optic disc with indistinct margins in the left eye.
While the patient’s demographics and body mass index (BMI) made idiopathic intracranial hypertension a consideration, the unilateral nature and the patient’s history pointed toward optic neuritis. A space-occupying lesion had to be ruled out as well. After confirming the patient’s healthy kidneys via a blood test, an MRI with FLAIR of the brain and orbits was ordered. We forwarded to radiology the patient’s history and clinical findings along with a message that the purpose of our MRI order was to “rule out demyelinating disease or tumor.”
The MRIs (Figures 4 and 5) showed multiple lesions, and the report stated that no mass was seen but “multiple nonspecific, hyperintense foci are seen in the periventricular white matter and subcortical white matter as well as enhancement of the optic nerve…the constellation of findings are most compatible with multiple sclerosis.”
Related: Imaging a choroidal nevus
The diagnosis of multiple sclerosis was made, and the patient was promptly referred to a neurologist for care.
While usually not a daily part of optometric life, neuroimaging does not need to be an intimidating subject. Worsening neurological symptoms from a possible tumor, vascular disorder, or demyelinating disease all warrant further investigation with a CT and/or MRI. Prompt referral as well as proper communication with the radiologist can ensure these patients receive the correct diagnosis and care.
1. Goldman LW. Principles of CT: multislice CT. J Nucl Med Technol. 2008 Jun;36(2):57-68; quiz 75-6.
2. Brown RD Jr, Broderick JP. Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. Lancet Neurol. 2014 Apr;13(4):393-404.
3. Lee HJ, Jilani M, Frohman L, Baker S. CT of orbital trauma. Emerg Radiol. 2004 Feb;10(4):168-72.
4. Saloner D, Uzelac A, Hetts S, Martin A, Dillon W. Modern meningioma imaging techniques. J Neurooncol. 2010 Sept;99(3):333-340.
5. Ge Y. Multiple sclerosis: the role of MR imaging. AJNR Am J Neuroradiol. 2006 Jun-Jul;27(6):1165-76.
6. Greenfield G, Arrington JA, Kudryk BT. MRI of soft tissue tumors. Skeletal Radiol. 1993;22(2):77-84.
7. Burrill J, Dabbagh Z, Gollub F, Hamady M. Multidetector computed tomographic angiography of the cardiovascular system. Postgrad Med J. 2007 Nov;83(985):698-704.