A 25-Year-Old Man With Painless Diplopia

Sumaira Nabi, MBBS, FCPS; Shahzad Ahmed, MBBS; Fateen Rashid, MBBS; Mazhar Badshah, MBBS, FCPS

Disclosures

August 09, 2016

Physical Examination and Workup

Figure 1.

Figure 2.

Upon physical examination, the patient is an alert young man who is oriented to time, place, and person. His vital signs include an oral temperature of 98.6°F, a regular pulse of 70 beats/min, and a blood pressure of 120/70 mm Hg. His respiratory rate is 14 breaths/min. His Glasgow Coma Scale score is 15/15.

Upon ocular examination, the patient is unable to adduct the right eye (Figure 1) and has nystagmus of the left eye with abduction. No lid swelling, ptosis, proptosis, or chemosis is noted. He also has left-sided relative afferent pupillary defect. Using measurement of meters (where 6/6 is the equivalent of the customary US units of 20/20), his visual acuity is 6/36 on the left side and 6/18 on the right side. Upon funduscopic examination, left optic disc pallor is noted (Figure 2). His cranial nerves are otherwise intact and symmetric. No signs of meningeal irritation, pyramidal weakness, or cerebellar dysfunction are present.

Figure 3.

Figure 4.

The patient's abdomen is soft and nontender. No clinical evidence suggests organomegaly or ascites. His bowel sounds are audible. The precordial examination reveals normal heart sounds. Auscultation of the lung fields shows normal vesicular breathing.

Laboratory analysis reveals a complete blood cell count and erythrocyte sedimentation rate within the reference range. Liver and renal function test results, serum glucose levels, ECG findings, and chest radiography findings are unremarkable. The antinuclear antigen test results, extractable nuclear antigen profile, HIV serology, and hepatitis B and C test results are negative.

The patient's serum angiotensin-converting enzyme levels are normal. His cerebrospinal (CSF) fluid routine examination is normal; however, his CSF oligoclonal bands are positive. MRI of the brain with contrast shows a T2 fluid-attenuated inversion recovery high-signal area in the pons, in addition to other scattered white-matter hyperintensities (Figure 3). His visual evoked potential shows delayed P100, with abnormal waveform on the left side more than the right side (Figure 4).

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