Nystagmus, diplopia seen in 11-year-old boy – Healio

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An 11-year-old boy presented to the University of New Mexico Hospital with 6 weeks of vomiting and food intolerance as well as a 13-pound weight loss over that same period.

At the onset of these symptoms, he went to an outside hospital and was discharged without any diagnosis or medications. Subsequently, he was seen at UNMH for vomiting and was given oral ondansetron, which did not relieve his symptoms. In addition to nausea, vomiting and weight loss, the patient was experiencing 3 weeks of constant horizontal binocular diplopia, worse at distance, “eye jumping,” difficulty concentrating and headaches. He denied vision loss, pulsatile tinnitus, amaurosis or oscillopsia.

Allison V. Coombs

Nisha S. Dhawlikar

His medical history was significant for gastroschisis repaired as a newborn, gastroesophageal reflux and a fall 2 weeks prior in which he hit his right temple against a tree without loss of consciousness or vomiting at that time. He had no ocular history and followed with an optometrist every 1 to 2 years without previously noted refractive error or strabismus. Given his persistent symptoms, the patient was admitted for treatment of his dehydration related to the vomiting, as well as a workup for etiologies of his recurrent vomiting and weight loss. His primary medical team also noted that the patient had a shuffling and unsteady gait.

Examination

Upon examination at bedside, the patient’s near uncorrected visual acuity was 20/20 in both eyes. IOPs by Tono-Pen (Reichert) were 11 mm Hg and 12 mm Hg in the right and left eyes, respectively, and he was able to identify all Ishihara color plates out of each eye. The extraocular motility examination revealed a trace right abduction deficit and a –1 left abduction deficit. Additionally, there was gaze-evoked jerk nystagmus in right gaze, left gaze and upgaze. On cover-uncover testing, there was an esotropia that was evident at distance and resolved at near that did not appear worse in either right or left gaze. The visual field was full to confrontation bilaterally. Pupils were 4 mm scotopically, decreasing to 2 mm photopically bilaterally without a relative afferent pupillary defect noted in either eye.

External and anterior segment exams were unremarkable. Fundus exam revealed tortuous vasculature in both eyes. The right optic nerve did not appear pale or edematous and had a 0.15 cup-to-disc ratio. The left optic nerve appeared to have trace superior and inferior edema without pallor. The rest of the fundus exam was unremarkable.

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Constellation of findings

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Source: https://www.healio.com/news/ophthalmology/20211130/nystagmus-diplopia-seen-in-11yearold-boy