Case MW 55

Case MW 55

Case Study no. 1 – Visual Snow


Px MW age 55 attended with the following progressive symptoms over the last 10 years which lead him to becoming increasingly withdrawn and reliant on his wife’s support. He was unable to go out without ear defenders, peaked cap and extensive research of details of any trip planned. The loss of confidence and independence affected his mental health and he was using alcohol as an escape from the distressing visual world he inhabited due to visual snow, double vision and ghosting.

MW had been to many Optometrists over the years but found no resolve. As the symptoms worsened, he was referred to the hospital eye service where an Ophthalmologist registered him as Sight Impaired and on the reason for registration he didn’t select any of the boxes but simply put in the comments box “Psychological”.

MW contacted PSS for advice on the wording on his Sight Impaired registration document as, now he was looking for work, he felt this would be detrimental to future employers. After initital telephone discussion we suggested MW come for an assessment.

Symptoms presented:
Vertical double vision (2 prism vertical at distance)
3 previous squint ops when young (described at school as lanky ‘crossed eyed’ 6ft 3inch with an alternating squint (note))
Ossilopsia (the world in constant motion)
Pallenopsia (after images ghosting)
Photophobia (bright light issues)
Visual snow syndrome (dots in his vision constantly, even when closed – and especially when looking at a blue sky)
Drinking alcohol daily to reduce visual sx
Wearing ear defenders, as the addition of noise on top of his vision problems, made the everything worse
Low confidence and self-esteem

Previous employment:
Carpenter – stopped due to diplopia
Gardener – stopped due to vision problems
Now unemployed and claiming PIP

Notable history:
Age 2 fell downstairs backwards resulting in back of neck trauma – (no treatment prior to note above about alternating squint.)

Age 8 fell off the back of a truck moving truck at approximately 30 mph and landed on cervical section of spine (top section). No hospital treatment as the carers on this day didn’t want to make much of it!
Edit update: MW tells me of at least 2 other incidents where there was potential for neck injury.
First examination PSS:
During the initial exam, Spectralis OCT showed his eyes healthy.

When approaching the test room he walked unsteadily with an awkward gait to the testing room chair.
He rarely made eye contact with either Anita or myself.
When covering each eye to test his muscles he had a tendency to flick his eyes to the right before returning to the centre – all of the cover tests were confusing for him as his world kept moving and he had double vision.
His visual acuity with his glasses prescription was 6/5 (better than 20/20).
I found not only that he had vertical double vision but a horizontal one too – I placed a 3 prism in his left eye and he said  ‘wow what have you done – that is magic’ .
The prism helped get the eyes focused more together.
I also noted that he had facial asymmetry – the left eye being higher than the right – he couldn’t tell me if this had always been like this (potentially this can cause the vertical element) – he said no one had mentioned this at previous examinations.

He had visited Bradford University eye department, in the hope that they would know what was wrong with his eyes. They recently prescribed vertical prisms, but I was finding quite different results and although he was wearing the glasses prescribed, he still wasn’t getting any relief from all the symptoms at the start.

My thoughts at this point:
I didn’t believe many of the vision symptoms were related to just his eyes.
Knowing the history of two ‘whiplash’ type injuries which potentially caused damage to the top section of his back (cervical section). Importantly, one of the nerve ganglion that come out of the brain stem at the C2/C3 are responsible for providing nutrients to the optic nerve sheath (called the Superior Cervical Ganglion – it isn’t part of the optic nerve but is responsible for maintaining optic nerve health. It is also something that is mentioned at the start of optometry training but is soon forgotten as it isn’t part of a normal eye test.) along with providing the sympathetic supplies to the cilliary and cornea.

We then did a colorimetry assessment, and he preferred a mix of blue and turquoise together. We tried the filter outside on a sunny day where he was experiencing a lot of visual snow and the filters ‘quietened’ the effect, but the snow was still there.

We discussed with him that our findings indicated that it was not his eyes causing the symptoms, but his neck and brain. This was a LOT for him to take in and something no-one had mentioned or explored with him.

This discussion was followed with a recommendation for him to watch some scientific research youtube videos on the subject. We also suggested he might like to arrange a visit to an Osteopath* or Chiropractor and that some xrays of his neck in various positions would help to see what was going on.

*There is no direct referral system for us to refer to a neuro spine specialist. We had previously approached a local Ophthalmologist about visual snow and disruption to vision in relation to neck and spine injuries as this was not the first time we had seen this type of Px. The Opthalmologist dismissed the suggestion. Therefore, we left it to the Px to pursue this when he was ready. The Px felt it was a lot to take on board as this was the first time anyone had offered an alternate suggestion and possible treatment pathway.

FEB 24 – Follow-up:
MW called to make an appointment for a follow up.
The transformation in him physically and mentally was astounding.
He walked with confidence to the test room without any hesitation, he was smiling and making eye contact! He had a shopping bag, as he had done some shopping on the way in. This was momentous as he had not been able to go shopping on his own for years.

In discussion we learnt he had ‘slept’ on the information that we had given, then decided to go see a local Chiropractor. The Chiropractor examined him and found a bulge in the right side of the Cervical area. MW said the Chiropractor was dubious as to how the treatment of re-aligning would resolve his symptoms but tried.
He has only had one visit to the Chiropractor and the results are amazing. MW said his symptoms have reduced by 80%. The first week he could feel his face relaxing (the bulge on the right is potentially pulling the bones apart on the skull and is the reason of the asymmetry – I didn’t measure the original difference but could see an improvement).
MW had stopped drinking alcohol almost immediately, as he no longer felt the need for this crutch. He was also able to look into his wife’s eyes which he hadn’t done for 10 years.
After the Chiropractor session he, almost immediately, felt his disjointed body and world coming together again.

Eye Exam no 2
His eyes were much more coordinated today – the ‘magic’ prism wasn’t needed. He had NO vertical double vision (although he was still wearing the glasses with the original prism in.)
He still has no depth perception and has no binocular vision as such.
The tick when looking to one side before re-centering his eyes when I covered them had almost disappeared.

Discussions about how he had forgotten what colour eyes his wife had came up as he hadn’t looked into her eyes for ages. He had been out on his own Christmas shopping and visiting coffee shops, which he hadn’t done for years (and when he did his wife would tell him to sit down and she brought the tray across.)
MW comments that he had lost 10 years of his life but now feels back together. He said he feels like he is a new person.

What Next?
I came up with a new prescription to update his glasses  – no prism for near and just a small prism in his right. (2 out)
He has another appointment with the Chiropractor soon – so we will await the results.
He enquired about the colorimetry lenses but these are not needed at the moment. (Interestingly when I researched more about brain injury – this is the colour that is favoured).
With the fact he has 6/5 vision and no double vision and no field defect the only reason we can see that is stopping him from driving (which he really wants to do) is the Sight Impairment Registration. I have made enquiries about how to reverse the registration and will arrange a referral in with back up information, so he doesn’t have too many hoops to jump to get the registration nulled.

Feb 3rd visit.

MW has now visited the Chiropractor 5 times and progress is generally good.i noticed on 2 occasions he still turned his body not his neck to regain eye contact – need to think about this as he has had 10 years at least of avoiding moving his head so quite natural.

Today we did an Esterman field test and he was clear. VA remains 6/5 both eyes. Still with the tenancy to fixate primarily with the right eye but easily alternates.

MV brought an album of photos from birth through to around 30 and we noted that his facial asymmetry started around the 2 years stage with a marked left esotropia around his teens. He also brought all the letters from the hospital eye clinic visits he could find. Quite often there were comments of 16 to 18 esotropia and that he couldn’t cope well with enclosed spaces visually. In 2021 he was registered Sight impaired and the reason given was “psychological”

We retried the blue /turquoise lens tint and still found a benefit to the visual snow reducing its effect. Transmission is approx 30% absorption. A 50% absorption tended to render clouds a 3d effect.

After MW visit I contacted the Chiropractor to discuss what he had found. There was a large restriction in the movement around the Atlas C2 and C2 which after treatment released.

i have ordered a distance pair of spectacles with a matching tint to the one from the colorimetry for him to use when needed.

Review next in 1 month -progress good so far.

Here is a photo of how MW perceived the world on our first meeting.

This is how the world should be seen .

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