Visual Change Intake

2025-11-09

Dr. Morgan Lee

RE: 

Dear Dr. Lee,

IDENTIFICATION:
This is a 68-year-old right-hand dominant female who was seen at the Regional Neurology Clinic on 2025-11-09.

REASON FOR REFERRAL:
Double vision and imbalance.

HISTORY OF PRESENT ILLNESS:
The patient has a history of hypertension, hyperthyroidism, and longstanding systemic lupus erythematosus treated with prednisone for approximately 20 years. She also has arthritis involving the hands, chronic neck pain, and a history of cervical spine pathology with multiple injuries since childhood. She underwent cataract extraction surgery, after which she developed persistent diplopia. The diplopia is described as predominantly horizontal, with images appearing side by side and occasionally varying in separation. It does not resolve with monocular occlusion, leading her to frequently close one eye and adopt compensatory head positions. The diplopia is exacerbated by fatigue and is particularly problematic during reading or computer use. She also describes visual misperceptions, including difficulty accurately identifying objects and occasional visual phenomena such as perceiving birds flying past.

She reports chronic imbalance, with a recent fall while entering from a balcony, resulting in impact with household furniture. There is longstanding numbness and paresthesia in the fingers and toes, as well as left lower extremity weakness, attributed to her cervical spine pathology and prior injuries. She notes progressive short-term memory impairment over the past six months, with difficulty in immediate and delayed recall tasks, though some details can be recalled with prompting. There is no reported dysarthria.

Relevant imaging includes prior MRI demonstrating cerebral atrophy and nonspecific white matter hyperintensities consistent with microvascular ischemic changes. There is no evidence of mass lesion or classic findings of progressive supranuclear palsy. She denies a family history of neurodegenerative disease.

FAMILY HISTORY:
There is no reported family history of neurodegenerative diseases.

SOCIAL HISTORY:
She is a former smoker, worked for the Ministry for Children and Families for 20 years, and attended business college.

PHYSICAL EXAMINATION:
On examination, she was alert and oriented. Gait assessment revealed postural instability. Cranial nerve examination showed persistent diplopia in all directions of gaze. Motor examination demonstrated no specific abnormalities in strength testing of the upper and lower extremities. Coordination was intact on finger-to-nose testing bilaterally. Sensory examination revealed preserved vibration sensation in the extremities. Balance testing showed postural instability.

NEURAL AND CRANIAL NERVE EXAM:
Pupils were not specifically documented, but extraocular movements revealed persistent diplopia in all directions. No ptosis was reported. Facial sensation and strength were not specifically documented as abnormal. Palate and tongue were not specifically commented on.

MOTOR EXAMINATION:
Tone, bulk, and power were not specifically documented as abnormal. Lower extremity strength was assessed with resistance testing and was not specifically abnormal.

SENSORY EXAM:
Vibration sensation was present in the extremities.

COORDINATION:
Finger-to-nose testing was normal bilaterally.

GAIT:
Gait assessment revealed postural instability. She was able to walk on toes and heels, but had difficulty with balance and postural stability.

INVESTIGATION:
Prior MRI of the brain demonstrated cerebral atrophy and nonspecific white matter hyperintensities consistent with microvascular ischemic changes. No classic findings of progressive supranuclear palsy were noted.

ASSESSMENT AND PLAN:
This is a 68-year-old female with persistent diplopia and chronic imbalance, with a history of cervical spine pathology and systemic lupus erythematosus. There is no evidence of brain tumor or structural brain lesion causing her symptoms. No other signs of Parkinsonism except postural instability. No evidence of progressive supranuclear palsy at this time.

The differential diagnosis includes neuromuscular causes of ocular symptoms, microvascular ischemic changes, and neurodegenerative disease. The following plan was discussed:
- Ordered blood work to check for neuromuscular antibodies to rule out neuromuscular causes of eye issues.
- Recommended repeating the MRI in approximately one month to assess for any changes, with a preference for scheduling at Regional Medical Center.
- Discussed the possibility of referral to a neuro-ophthalmologist for evaluation and consideration of prism glasses to address visual disturbances.
- Conducted cognitive screening tests, including clock drawing, number-letter sequencing, and word recall tasks.
- Continued current prednisone therapy for inflammatory symptoms related to systemic lupus erythematosus.

There is no treatment for progressive supranuclear palsy at this time. Further evaluation and follow-up are planned based on test results.

I will follow up with the patient after the results of the blood work and repeat MRI, and will consider referral to a neuro-ophthalmologist as indicated.

Dr. Morgan Lee, Neurology
Regional Neurology Clinic
cc: Family Physician