Thursday, April 25, 2013

I'm stumped

Okay, people, time to see how good you are at being armchair neurologists.

This is an unusually challenging case I saw yesterday, involving a 54 year-old lady. Her internist had referred her to me because of  some recent changes in her vision. The following is quoted verbatim from my chart note:


"She has 2 glasses prescriptions, one for near and another for distance. 1 month ago she had an annual optometry check-up, and was told she needed a new near-vision prescription. She ordered the new glasses, and picked them up last week.

Since then she finds that when she puts on the new glasses things look “funny and unclear.” This resolves with taking them off, and doesn’t occur with the distance-glasses on, or using her previous prescription."


This case really has me stumped. So if any you are able to figure out what the problem is, please write in.

68 comments:

Julie said...

good grief ....

Nicky said...

I'd say it could be a number of things, the lenses could be the wrong shape for the prescription (some must absolutely be round), there was a fault in production and the lenses are a different prescription or have warped, the pupilary distance was measured wrong, or one of the coatings was not applied correctly. My advice is to have the prescription of the lenses checked or not bother and have them redone.

Usually the eyes will adjust to faults in the lenses over time but because she uses 2 different prescriptions her eyes absolutely cannot adjust. This happened to someone I know her lenses made the world u-shaped and upside down and she didn't know until she had a new prescription because her eyes had adjusted.

If it's a problem with her eyes or brain I have no idea. These are just the things I can think of as a glasses wearer (and who most of these have happened to).

Anonymous said...

She's wearing someone else's glasses by mistake?

Anonymous said...

She picked up the wrong glasses?
Her ophthalmologist screwed up?

jimbo26 said...

The new glasses are for somebody else ? They got mixed with hers ?

Anonymous said...

Not being funny, I assume the internist has a reason for the referal, but could it just be the new glasses? I have been wearing glasses all my life (too many years to admit), and whenever I get anew prescription, they give me a headache and make things look funny/ blurry for a few days until I get used to them.

Anonymous said...

Were the glasses made right? I've had new glasses that were bent and caused blurriness once, and once when they were just the wrong prescription.

Seems too obvious, but if the old pair and the far pair are fine, it suggests the problem is in the new glasses.

Marcia said...

Lenses were put in wrong!
Left in the right side, right in the left side!

ZD said...

Has anyone checked the script on the glasses? It may have been a + when it should have been a - or vice versa.

FireCap5 said...

Just a lowly EMT-B, but the first question that comes to mind is did they get the prescription right with her glasses? Did they give her the right pair of glasses when they came back from the lab?

A simple mix up could be the answer. The new glasses are the only thing that has really changed, unless her signs and symptoms aside from the glasses reveal anything?

Justin said...

She either doesnt need the new script, or the wrong script is in her new glasses.

Anonymous said...

It's a Tum-ah! GET TO DA CHOPPA

RehabRN said...

Grumpy:

I know, I know (raised hand and waves it)!

She has old glassitis. She's got that spot on her nose for the old glasses, but the new ones just don't fit, hence she takes them off.

See a little deductive reasoning and all is well.

What difference does it make if she can't see?

Officer Cynical said...

This sounds like something someone would call the police for...

Birdie said...

My prescription was put in upside down once.

Anonymous said...

The new glasses were made of a material she is allergic to. Everytime she puts them on, her eyes start to water and makes her vision blurry. Prescribe her an antihistamine and move on to next patient.

Anonymous said...

@Officer Cynical--I'm sure you'll be getting a call!

-Allison

awesomesauciness said...

Obviously, she needs an appendectomy...stat!

Geez doc, weren't you paying attention during the first year's "Changes in Vision: A Revenue Stream" was presented?

Anonymous said...

Short-sighted internist and most people who have responded are presbyopic (they sound too serious to be joking!) TWO pairs of glasses, ONE for NEAR an ONE for DISTANCE. 'Near' won't work for distance and 'distance' won't work for near. Neither will work for both near and distance. Capiche?

Anonymous said...

The axis is off on one of the lens. I had the exact same symptoms and one lens was at .13° instead of 13° or something like those numbers. Easy check - close one eye and wiggle the frames on your face and see if you can find a spot where they work.

Although the reasoning behind two pairs (verse bi-focals) could also indicate a contributing factor.

MBee

Nurse Lilly said...

Ocular syphilis, from having set her glasses down on a toilet seat.

Medic2RN said...

She should get crystalens surgery - how can she be expected to keep up with all those damned glasses!

Anonymous said...

she's just fine. the internist, however, not so much.

Anonymous said...

Well, what the hell did you learn in med school Dr. Grumpy? 4 years didactic and clinical, 4 years of residency, and YOU can't figure this one out?!?

Call your med school and tell them you want your money back!

;)

Ms. Donna said...

While I am not sure, I do agree that the previous comments are the most obvious (horses, not zebras, eh?) Can you get the optho to check her glasses? They may be wrong. The new glasses seemed to start the trouble, but that could be coincidence.
Other thought could be tumor in optic system but I am sure that was ruled out.
Anyway, hope the pt is ok.

Ivan Ilyich said...

She's confused about which is the newer.

Rosie1925 said...

OMG! Send her back for an eye exam, and a check that the darn glasses are right! Rule out the easy first! Stupid internist...or, more likely, internist's stupid malpractice insurance.

Mathi Bear said...

I too am stumped. I see no reason why a doctor would refer someone for this. Perhaps the referring doctor needs vision/hearing checked.

Anonymous said...

It's SO obvious. You need to refer her to an OB/GYN.

Anonymous said...

Neurologically speaking, it's nothing to do with the glasses...

...it's that mustache and eyebrows they're attached to.
Now if she really wants to feel funny- tell her to take up cigars.

Packer said...

Sounds like a mix up in glasses, which is which. but I will tell you that I experienced blurry vision with new glasses and as it turned out my eyelashes would sweep the inside of the lense everytime I blinked, leaving an oil spot on the lense. No lie. No optho person figured it out for months. Finally I figured it out.

Anonymous said...

I would get an MRI.

Anonymous said...

First pair were fake, so 2nd pair with real Rx look funny. Check first Rx and then check lens itself

jrhodes85 said...

I'd say first referral should have been to lenscrafters to make sure the rx was prepared correctly. Also it's likely that because she is wearing two different pairs that her presbycutic (I may or may not have made up that word) eyes are having trouble adjusting to so many changes. She should probably just get bi/trifocals if she needs distance and near correction.

Alternatively she could have cataracts or AIDS or something.

bobbie said...

She's putting the new glasses on over the old...

a.generic doc said...

A clear case of Presbyopicus Optometricus Screwupicus.

Anonymous said...

Pop-up ads on her Google Goggles?

D said...

Was the patient hyperopic originally? It could be "second sight" due to myopic changes in the lens as a consequence of new-onset nuclear cataracts.

Anonymous said...

Has she tried beer goggles?

Sallie B. said...

Well, I don't know, but I have a similar problem. Last November
I was prescribed new distance lenses. When I put them on, things
look weird--it is hard to describe, but I cannot see well when wearing them. The optometrists' office swears they are correct. I just gave up and went back to wearing my old glasses. I will ask the doctor to check them when I go back this year.

Packer said...

Given the number of comments it seems to have everyone stumped, How about near lens in one side far lens in other side. We will all be laying awake tonight mulling the problem and our collective vision will be blurry come morning. I hat that feeling of not knowing.

Anonymous said...

I have migraines of the "little stroke" severity and I cannot wear any of the bifocals. I have tried three lens "styles". Once I had a prescription error that caused everything to have a "break". i.e. Fences looked as it they were lying on the ground. Another time, they put the wrong + / - in one lens and I couldn't bear to look thru that one. I also have eyelashes that smear the lens. Print without a space blurs and I've never been able to read a license plate while driving. If the timeline started with the new glasses, that's most likely the problem but if not, I hope it is something minor and I think she is in good hands either way.

Anonymous said...

Was she wearing the near-vision glasses when trying to see far away?

Rakaha said...

The glasses didn't by any chance come with that plastic stuff over then that is found on cell phones and other electronics during transport/delivery? And if so, did she take the plastic shielding off?

Anonymous said...

Either the new prescription for glasses was wrong or the new glasses are not as prescribed.

Steeny Lou said...

"...quoted verbatim from my chart note."

How was this chart note produced? In handwriting? If so, by whom? And was it written during sleep deprivation? If it was transcribed from a recording, was it done by a tired/underpaid/overworked medical transcriber? Was voice recognition software involved?

I'd want to double-check with the originator of the note before going further.

was1 said...

advise her to not use highball glasses when drinking martinis. and vice versa.

MadMT said...

I haven't read the other comments, but I had that happen with my near-vision glasses. They had made the Rx negative instead of positive.

Anonymous said...

I don't have any answers, but can tell you that I have had glasses due to nearsightedness for 25 years, and always get fitted for my glasses and contacts at my opthalmologist's office. This this year, for the first time ever, I have had to go back and get the prescription corrected 3 times. And I still can't see as sharply as I used to. I finally gave up because the lens lady at the doctor's office basically told me the problem is me, not them.
I do have rheumatoid arthritis and I wonder if that is what is causing my vision problems. I was tested for tear production and was told my eyes are not dry or anything, so I don't really know what's going on.

Anonymous said...

It is the glasses, not the person. Why on earth would she be referred to you for a neurological problem if she doesn't have the problem when she wears her old glasses?!

Her internist needs to be prescribed a vacation.

Dr.M said...

Rx: Bifocals.

Anonymous said...

I once had glasses that they initially had the right and left lenses switched; so the prescription was right, but I still couldn't see.

Ken said...

The glasses still have the stickers on them that the doc uses to make notations for measuring nose height.

Anonymous said...

The differential should include early dementia, TBI, and alcohol related impairment.




Oh wait, you mean what's wrong with the PATIENT?

danielle said...

The answer is - make sure that the internist is really a liscenced MD - why would he refer her to you instead of hitting her aside the head and telling her to go back to her optometrist? DUH

Anonymous said...

If this resolves with taking them off, that means she doesn't need correction eye glasses for near-vision. Her eyes still see well with the old prescription because they got used to adapt to that correction.

Unless she got a beginning of macular degeneration, but that would show on the distance-vision too.

Anonymous said...

Maybe she had a myopic shift from the recent addition of an antiepileptic medication? This would make her distance better for close up, and her new reading glasses wouldn't work very well

peace said...

Let's hope he was trollling you. That, or the old lady made him write so, while holding a knife around his neck! Be ware of here. She might be dangerous!

warmsocks said...

Anon 6:39
I am convinced that people with RA can't get a good rx for glasses. If inflammation levels affect vision, fluxuations in inflammation will lead to fluxuations in the amount of correction needed. That seems pretty obvious to diagnose, nearly impossible to fix. :(

Abigail Cashelle said...

Hey, wait, why is the internist involved anyways? I feel like this ought to be a discussion between the patient, her caregiver, the optometrist, the lenscrafter, and possibly a salesperson or two.

In fact, I feel like the neurologist makes more sense than an internist at this point. You could be asked to judge whether or not she understood what it was she was saying or remembering the difference between up and down. Plus, a visit to your office costs more, so therefore it must be worth more. QED.

Abigail

BobF said...

If she'll just turn the robotic vibrator off, everything will clear right up.

Charles said...

Nystagmus? and maybe she only notices it when she has on her new near-vision glasses?

(Hey, my guess is as good as the next yak herder's)

Eileen said...

When the same thing happened to me a different optometrist checked and realised the lens wasn't properly centred on the pupil on one side - only a fraction of a mm but enough. Luckily the lenses were large and he simply cut them down to fit smaller frames as spares - wasn't making much money as they were old frames he used. I'd used the glasses and just about got used to them but was never entirely happy.
My daughter was talked into sunglasses with photochromic lenses for driving - except they were an older version and useless - with the same problem to boot. The same optometrist spotted they too were made incorrectly - the original company was a chain who would have lost their profit had they corrected the fault. He was a independent practitioner who cared about his clients - and was mostly cheaper than the other lot despite their claims.

Aeris said...

We had a new onset headache referred to us once. The word "conversion" even came up.

Upon closer questioning, kid's been sick a week with a nasty virus and gastro, as was the rest of the family. Never had headaches before, so he didn't know what was going on. We reassured him he'll feel better when the virus resolves.

History is important.

For those trying to answer seriously, and perhaps not familiar with sarcasm, the actual answer is "the internist did not take a proper history, and made an inappropriate referral."

Anonymous said...

She maybe taking mega narcotics,or got a bad batch of them...wood etoh,Prescribe high doses of Prednisone..... or not

Anonymous said...

She should go back to the optom, the lenses are wrong for her.

Will I seem totally rude by saying DUH and WTFREALLY???

MDaisy said...

Her new lenses are probably not the correct ones. In other words, somebody screwed up and inserted the wrong lenses.

Anonymous said...

great case, grumpy.

about peed myself laughing about that one, mostly because i could see myself getting that exact same referral, except in my situation without a shred of accompanying documentation.

keep up the great work!
-fellow swinger of the hammer

 
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