Case Study: Morning Pulsatile Visual Disturbances and Diplopia in a Young Male

Case at a Glance

A 20-year-old male with a history of daily vaping and recent significant weight loss presented with a several-month history of pulsatile visual phenomena, blurry vision, and diplopia, most prominent in the mornings.

Patient's Story

A 20-year-old male reported a distressing onset of visual disturbances over the past few months. He described that upon waking, his peripheral vision would have a 'reddish hue' that was 'pulsing.' This sensation was also present when he closed his eyes. Concurrently, he experienced episodes of blurry vision, an inability to focus his eyes, and transient double vision. While these symptoms were most severe in the morning and typically subsided within a couple of hours, they could recur intermittently throughout the day. The patient noted a significant, intentional weight loss of approximately 50 pounds over the preceding six months. His social history was positive for daily nicotine vaping, and he denied taking any regular medications.

Initial Assessment

The patient is a 20-year-old male with a height of 5'11" and a weight of 180 lbs, resulting in a BMI of 25.1 kg/m², placing him in the 'overweight' category. His chief complaint consisted of episodic, pulsatile visual disturbances and diplopia. The strong association with waking in the morning was a key feature. His recent history of significant weight loss was noted, which can be a pertinent factor in various systemic and neurological conditions.

The Diagnostic Journey

Concerned about the persistence and nature of his symptoms, the patient sought advice and was strongly recommended to pursue an urgent in-person medical evaluation. The initial consulting advice emphasized that a comprehensive eye examination by an optometrist or ophthalmologist was critical. This workup would need to include a detailed history, a dilated fundus exam to inspect the optic nerve and retina, and imaging such as Optical Coherence Tomography (OCT). Given the pulsatile nature of the visual disturbance and associated transient diplopia, differential diagnoses included conditions causing increased intracranial pressure, such as Idiopathic Intracranial Hypertension (IIH). While IIH is typically associated with weight gain, it can occur in other demographics. Other possibilities considered were atypical migraines with aura or other neuro-ophthalmic or vascular conditions. It was determined that if the ophthalmologic exam was unrevealing, a referral to a neurologist would be the necessary next step.

Final Diagnosis

Pending Full Evaluation. Based on the symptomatology, the leading differential diagnosis is a condition causing increased intracranial pressure, such as Idiopathic Intracranial Hypertension (IIH), which requires confirmation. Other neuro-ophthalmic conditions remain a possibility pending a full workup.

Treatment Plan

The immediate plan is for the patient to undergo an urgent, comprehensive ophthalmologic examination. Key components of this exam will be a dilated fundus examination to assess for papilledema (optic nerve swelling), formal visual field testing, and intraocular pressure measurement. His blood pressure should also be formally checked. If papilledema is present or suspicion for IIH remains high, the plan would be to proceed with neuroimaging (MRI/MRV of the brain) to rule out other structural causes, followed by a lumbar puncture with measurement of the opening pressure for definitive diagnosis.

Outcome and Follow-up

The patient acknowledged the potential seriousness of his symptoms and the need for an urgent specialist consultation. The outcome of the case is pending this evaluation. Close follow-up with ophthalmology, and potentially neurology, will be essential to establish a definitive diagnosis, initiate appropriate treatment to alleviate symptoms, and, most importantly, preserve long-term vision.