Sudden onset of pain in the eye and blurring of vision

doi:10.1136/bmj.a3111

From trainee to consultant, BMJ Group offers doctors around the world tailored information, special events, learning resources and recruitment services at every step along their career path.

... by doctors, for doctors, for patients
We are open for entries!

Online learning

BMJ Learning

High-quality CME / CPD for doctors and other healthcare professionals. BMJ Learning features hundreds of accredited, peer-reviewed learning modules in text, video, and audio formats. Find out more

Courses and Qualifications

BMJ Masterclasses

BMJ Masterclasses, led by experts, help clinicians to use the latest evidence and recent guidelines in practice and meet their CPD/CME requirements. Find out more

Exam Preparation

The leading provider of online exam preparation, helping over 167,000 healthcare professionals to pass their exams. Find out more

onExamination

Search all BMJ education articles:

From

Limit by

The BMJ iPad app brings you the best of print and online, including live links to the latest news, blogs, video, and podcasts. Get the BMJ iPad app.
You can use bmj.com to help you with your continuing medical education. Find out about CME/CPD credits for BMJ articles
Keep up to date with cardiology: Access the latest cardiovascular medicine resources from across BMJ Group.
Countdown to London 2012: BMJ Group's Olympics portal highlights latest Olympics and sports medicine-themed research, comment and learning

Access to the full text of this article requires a subscription or payment. Please log in or subscribe below.

Neha R Chopra, foundation year 2, medicine,
Daniel A Jones, specialist trainee 3, cardiology,
Narasinha Gadi, trust senior house officer, medicine,
Farhad Huwez, consultant physician

¹Basildon Hospital, Basildon and Thurrock NHS Trust, Nethermayne, Basildon Essex SS16 5NL

Correspondence to: D A Jones danieljones{at}doctors.org.uk

A 64 year old man was admitted with sudden onset of pain in his right eye, blurred vision, and double vision on looking to the right. His medical history included hypertension, myocardial infarction, and a stroke from which there was no residual deficit.

Neurological examination identified intention tremor in both arms, horizontal nystagmus, and diplopia on looking to the right. He had no motor weakness, but the left plantar was extended. Examination of his face provided clues to the diagnosis (figure⇓).

Questions

1 What does the figure show and what is the likely diagnosis?
2 What is the differential diagnosis?
3 How would you localise the lesion in this patient?

Answers

Short answers:

1 The figure shows a unilateral partial ptosis, miosis, and apparent enophthalmos of the patient’s right eye, consistent with Horner’s syndrome. The sudden onset of the symptoms, the vascular risk factors, and the findings of the examination make Wallenberg (lateral medullary) syndrome the most likely diagnosis.
2 Horner’s syndrome is caused by interruption of the sympathetic nervous system and it can originate anywhere along the pathway. Lesions can be central: (brainstem stroke, demyelination, syringomyelia, or spinal cord tumour), preganglionic (Pancoast’s tumour, cervical rib, mediastinal mass, thyroid mass, or surgery), or postganglionic (carotid artery aneurysm or carotid dissection).
3 A thorough history (checking for weight loss, neck pain, and vascular risk factors) and examination (for example, checking the neck for masses and scars, examining the supraclavicular area for evidence of consolidation, and performing a thorough neurological examination for associated signs) may help localise the lesion. Investigations depend on the likely underlying cause but include magnetic resonance imaging (MRI) of the brain or spine and computed tomography of the chest.