Episodic blurred vision, in addition to cerebral infarction, do not miss this cause

*For medical professionals to read and refer to the wonderful case analysis, it is worth seeing! Many diseases in neurology have ocular symptoms, such as cerebral hemorrhage, cerebral infarction, multiple sclerosis, neuromyelitis optica, myasthenia gravis, hepatolenticular degeneration and so on
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If the visual path is involved, it can lead to vision loss or visual field defect.
This patient has had episodic blurred vision in the right eye for 1 month.
The first reaction is, what disease do you think of? Let's have a look! Medical record data A 68-year-old female was admitted to the hospital mainly because of "episodic blurred vision in the right eye for 1 month and aggravation for 2 days"
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The patient developed episodic blurred vision in the right eye after catching a cold 1 month ago, manifested as blurred vision, no double shadows, with swelling of the periorbital skin, lacrimation, and conjunctival hyperemia, which spontaneously relieved for a few minutes
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It occurs once every 3-4 days
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Half a month before hospitalization, the patient felt that the right eyelid was heavy and difficult to lift during the seizure.
No obvious abnormality was found in the CT scan of the head at the local hospital (Figure 1).
Give "diclofenac sodium eye drops" eye drops, the symptoms can be relieved, but still occurs once every 3-4 days, and the duration is gradually prolonged
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Two days before hospitalization, the above symptoms appeared again, and the right eyelid could be partially lifted for about 14 hours.
The head MRI in the local hospital showed subacute cerebral infarction (Figure 2).
For further diagnosis and treatment, he came to our outpatient clinic
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The patient's past history and personal history were unremarkable
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Nervous system examination: cranial nerves: bilateral pupils are equal circles, the diameter of the right side is about 2mm, and the diameter of the left side is about 3mm, the light reflex exists, the right palpebral fissure is small, the left side is normal, and the eyes move freely in all directions
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Autonomic: There is less sweating in the center of the forehead on the right side than on the left side
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No obvious positive localization signs were found
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Figure 1 and Figure 2 ask According to the results of head MRI, is the patient really a cerebral infarction? Can the eye symptoms be explained? Therefore, we perfected the relevant examinations: blood, urine, stool routine, five items of coagulation, total biochemical items, and infection and immunity indexes were all normal
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Female tumors: carcinoembryonic antigen 131.
6ng/mL↑, CA199 76U/mL↑, CA125 171U/mL↑, CA153 42.
26U/mL↑, ferritin 318ng/mL↑
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Chest CT (Fig.
3): point lesions in the apical segment of the right upper lobe with mediastinal and right supraclavicular lymph node metastasis, enhanced scanning is recommended
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There are multiple micronodules in both lungs, and a 6-month review is recommended
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Multiple cords in both lungs, mild interstitial changes in the posterior basal segment of the right lower lobe
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Enhanced brain magnetic resonance scan (Figure 3): abnormal enhancement signal in the left parietal lobe, considering the possibility of metastases in combination with the medical history
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Abnormal signal in sella, further examination is recommended
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Figure 3 Chest CT and head MRI enhanced scan According to the patient's symptoms, signs and auxiliary examinations, the bottom line was unraveled, and the diagnosis was: Horner syndrome; right upper lobe cancer (high probability)
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 In terms of treatment, he was transferred to thoracic surgery and oncology for further surgery, radiotherapy and chemotherapy and other specialist treatments
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 Review: Horner syndrome Horner syndrome is cervical sympathetic nerve palsy syndrome
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For any reason, the passage of the sympathetic nerve center to the eye is compressed and damaged, causing the syndrome of pupil dilation on the affected side, retraction of the eye, ptosis and facial anhidrosis on the affected side
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▌ 【Anatomy】The cervical sympathetic pathway can be divided into three levels of neurons: the first level neurons (central neurons) originate from the posterolateral side of the hypothalamus and descend along the ipsilateral brainstem and spinal cord to the ciliary spinal cord center (cervical 8 - Lateral angle of thoracic 2) is the second-order neuron, and the sympathetic nerve fibers sent from it follow the anterior root of the spinal nerve root out of the intervertebral foramen and ascend the sympathetic trunk to the upper cervical sympathetic ganglion (third-order neuron) ) ascends in the neck with the internal carotid artery, passes through the cavernous sinus and the internal carotid artery sympathetic plexus, and enters the orbit with the first branch of the trigeminal nerve through the superior orbital fissure, where it innervates the dilator dilator muscle and smooth muscle of the eyelid
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 Therefore, if any of the above neurons have problems, Horner syndrome will occur [1]
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▌ [Clinical manifestations] 1.
Mydriasis: due to paralysis of the dilator muscle of the iris, but the light response and vergence response exist; 2.
Small fission: Müller's muscle innervated by the cervical sympathetic nerve is attached to the upper and lower tarsal plates.
The upper and lower edges play an auxiliary role in the contraction of the upper and lower eyelids, that is to say, the Müller's muscle plays an auxiliary role in the lifting of the upper eyelid, and the upper eyelid is lifted by about 1-2mm; and the lower eyelid is pulled down.
effect
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Therefore, in addition to the ptosis of the upper eyelid, the small eye fission is also caused by the lifting of the lower eyelid; 3.
Invagination of the eye: related to the muscles behind the eyeball; related to autonomic disorders
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▌ 【Diagnosis】1.
Diagnosis: unilateral miosis, ptosis, and invagination
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2.
Localization diagnosis: give 1%~2% epinephrine, (1) if dilation is seen, the lesion is located on the path from the superior cervical ganglion to the peripheral nerve; (2) no dilation is seen, and the lesion is located in the superior cervical ganglion Formerly, it was central Horner syndrome
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3.
Qualitative diagnosis [2]: ▌ [Treatment] 1.
Treatment of the cause: anti-infective treatment for those with inflammation, radiotherapy, chemotherapy, and surgery for those with tumors; 2.
Symptomatic and supportive treatment: local application of eye drops to relieve symptoms
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▌ 【Prognosis】Depends on the cause
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1.
Peripheral Horner syndrome can be given 1%-2% epinephrine locally, 3 times a day, the symptoms such as ptosis and miosis can be relieved, but the sympathetic nerve recovery needs to be administered continuously for 4-5 weeks; 2.
In case of trauma For those who cause it, it will take 6 weeks to 3 months to improve symptoms
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References: [1] Martin T J.
Horner Syndrome: A Clinical Review [J].
ACS Chem Neurosci, 2018, 9(2): 177-186.
[2] Davagnanam I, Fraser CL, Miszkiel K, et al.
Adult Horner's syndrome: a combined clinical,pharmacological,and imaging algorithm[J].
Eye(Lond), 2013,27(3):291-298.
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