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A 35-year-old woman presenting with pain, reduced right-eye vision, and headache
Digital Journal of Ophthalmology 2015
Volume 21, Number 2
May 13, 2015
DOI: 10.5693/djo.03.2015.03.002
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Brinda P. Shah, MS, FRCOphth | Moorfields Eye Hospital, London, United Kingdom
Jonathan Clarke, MD, FRCOphth | NIHR Biomedical Research Centre at Moorfields Eye Hosital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
A 35-year-old woman presented to the emergency department of Moorfields Eye Hospital with a 10-day history of pain, reduced vision in her right eye, and headache. She described the visual disturbance as “sparkly lights.” She had undergone bilateral lensectomy at the age of 7 weeks for congenital cataract and was aphakic. Her corrected visual acuity was 6/36 in each eye with +19.0 D sphere correction.

For 2 years prior to this episode she complained of recurrent headaches every 2-4 months associated with similar visual aura. The headaches were not unilateral, and the visual symptoms were not limited to one side. She had been diagnosed with migraine in her teens; however, the headaches had now become more frequent, without change in nature. She described “flickering lights” that presented suddenly with reduced vision, “as if looking through a steamy window.” Each episode lasted 3-4 hours. She also noticed “rainbows” around bright lights, with “speckles, flashing lights, and blotches” in her vision. In the weeks before presentation, these attacks increased in frequency to almost daily, and sunlight was volunteered to be a trigger. There was no associated nausea, weakness, or other systemic symptoms. The ocular symptoms were now predominantly unilateral but similar to the symptoms that had been attributed to migraine in the past.

Previous assessments by ophthalmologists during the 2-year period prior to presentation found that her vision was stable, with deep anterior chambers. Vitreous was present up to the pupillary margin, but was not in the anterior chamber. The anterior hyaloid face was intact, intraocular pressures (IOPs) were normal, and the optic discs were healthy. No focal defects were detected on visual field testing. On one previous visit, when her IOP in the right eye was found to be elevated, vitreous was noted in the anterior chamber, although there was no evidence of iris bombe. The angles were open on gonioscopy, with scattered peripheral anterior synechiae in 90°-180° in the right eye, whereas the left eye had open angles in all quadrants, with no synechiae. The past intraocular surgery was considered the likely etiology for the peripheral anterior synechiae. During this period, a neurologist confirmed that these episodes were representative of migraine.