Chapter 13 Cases
Case #1 Double Vision and Unilateral Eye Pain
A 48 year old woman came to the emergency room with worsening
left eye pain
and intermittent double vision.
Approximately 4-5 years ago, the patient had begun to have
left frontal and left
that occurred intermittently at first, and then went on an
almost daily basis.
The headaches continued to occur but were relieved by
One and a half years prior to presentation she began to have
drooping of the left eyelid and dilation of the left pupil.
noticed that her
left eye occasionally drifted to the left,
patient was observant, and she noticed that her
diplopia was worse when
looking to the right.
When covering each eye alternately, she reported that the
two images did not overlap.
In fact, the
image from the left eye appeared to
the right, and slightly above the image from her right eye.
gradually progressed from intermittent to continuous, and her headaches were
no longer relieved by up to 12 ibuprofen tablets per day, so she came to the
Vital signs: Temperature = 98.7º
Pulse = 78
BP = 180/90
Neck: supple with no bruits
Heart: regular rate with no murmurs
Abdomen: soft, nontender
: alert and oriented x3.
Speech fluent, with intact naming
Recall was 3/3 words after 5 minutes.
: Visual fields full.
Right pupil 4 mm,
constricting to 3 mm with direct and consensual light stimulation, and
Left pupil 6 mm, with no direct or consensual
response to light and no response to accommodation.
Left eye had
limited but not absent upgaze, downgaze, and adduction.
with left palpebral fissure 6 mm and right 9 mm.
Corneal reflexes intact.
Facial sensation intact.
Face symmetrical, other
than the ptosis already described.
Normal palate and tongue movements.
: no drift.
Strength 5/5 throughout.
: all grade 2+, with normal plantar response.
: normal finger nose and heel shin.
: intact light touch, pin prick, vibration, and joint position sense.
Normal graphesthesia, no extinction.