Case RK21

Case RK21

Px RK 21 year old    – case of Functional Neurological Disorder 

21 Year old Female , 

History of classic and common migraines in the past, she did have a couple of occasions when her vision went black but returned. 

History of loss of function of lower leg in the past (she was an active dancer when younger and it stopped her) 

No Other obvious alignments 

No hx of and head trauma

She was seen previously (a couple years before ) in a Neuro department when she lost the use of her lower leg , a full body MRI was done along with a head one but nothing was found. She had a diagnosis of severe migraines and it was left at that.

April 23 she was in the University library studying  – over a period of 30 minutes her vision became dull , washed out  (bilateral equally) to the extent that she had to ring a friend to take her home. She had had a severe migraine a day or so before. She attended A&E and then ended up in the Ophthalmology department.  Her vision didn’t recover.

They did a VEP test, she said that there wasn’t much discussion about it afterwards.

SHe was then referred to Neurology where they came up with the Functional Neurological Disorder – presumably by adding the previous Neuro history.

Meds: Citalopram , Amitriptyline , Sumatriptan (when she feels a migraine coming on)  Just had botox to her forehead to help with the headaches.

No Head MRI done since the vision loss.

Registered Severe Sight Impaired December 23. 

When RK attended she was using a long cane and came with Mum.
OCT all clear and normal , Disc maps showed all within normals.
Slitlamp nothing remarkable.

Had been planning to take her driving test a May 23 and had been prescribed, in the past, rx for studying of +0.50 ou and rarely wore.

Observations: Unsteady on feet walking without the cane, Eye Contact mead all the time. Had to be guided to the test chair. Noted an alternating Exotropia as if alternating fixation at a rate of 2 changes per second at times (Like a slow nystagmus!)

VA Bailie Lovie at 1 m = 0.9  – so around 6/360 both eyes – having to scan to find the letters.

Retinoscopy:  very large spasm of accommodation – between -4.00 and +2.00 at times. I left her in a +1.50 pair of lenses and settled it out at -2.25R L-2.50 

Pupils:  Noted in room lighting 8mm Direct 3 Consensual 3. No RAPD

10 seconds torch each eye showed constriction to around 5mm but then released to 6mm

Cover test: at 40cm showed an alternating Exot of 16 prism IN (R 7IN L 9IN). – Immediate reaction was that there was just one fixation target.

Same at distance of 2m 

Interestingly the pupils narrowed to around 5mm with the rx and prism in place and her reaction was very positive.  VA hadn’t changed by any appreciation but her comments of seeing mum much clearer at the door 3m away was positive.
I asked her to walk with the trial frame with the rx in place – much more confident ‘the world feels more peaceful’ was her comment!

Colorimetry: Was difficult due to her VA so I used a large black and white image as a target.
She had a very negative reaction to Green , Even more negative to Pink but a huge positive reaction to Purple D3.

These were placed in the support and asked her to try these around the practice and at the door (Decent sunlight and 50% overcast) Her comments was ‘I have not seen like this for ages’

We have agreed to put the rx in an inexpensive frame along with fresnel prisms  for a month to see how she goes.
I haven’t put the tint in place for now until I can gauge how she is doing.

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