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 Table of Contents    
CLINICAL IMAGE
Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 211-212  

Rapidly reversible visual loss in posterior reversible encephalopathy syndrome: An ophthalmologist's enigma


1 Department of Pediatric Ophthalmology, Strabismus and Neuro-Ophthalmology, Nimmagada Prasad Children's Eye Care Centre, GMRV Campus, Visakhapatnam, Andhra Pradesh, India
2 Department of Retina and Vitreous Surgery, L V Prasad Eye Institute, GMRV Campus, Visakhapatnam, Andhra Pradesh, India
3 Department of Pediatric Ophthalmology, Strabismus and Neuro-Ophthalmology, Jasti V Ramanamma Children's Eye Care Centre, L V Prasad Eye Institute, KAR Campus, Hyderabad, Telangana, India

Date of Web Publication20-Nov-2015

Correspondence Address:
Dr. Virender Sachdeva
Department of Pediatric Ophthalmology, Strabismus and Neuro-ophthalmology, L V Prasad Eye Institute, GMRV Campus, Hanumanthwaka Junction, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.169886

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   Abstract 

Posterior reversible encephalopathy Syndrome (PRES) may present with a sudden onset reversible visual loss under special visual conditions. Such patients' may initially be misdiagnosed as Malingering. Ophthalmologists may be the first physicians to be confronted by such patients. Hence, a knowledge of this condition is vital to diagnosis and management of such conditions.

Keywords: Encephalopathy, posterior, reversible, visual loss


How to cite this article:
Sachdeva V, Garg R, Pathengay A, Chandrasekharan A, Kekunnaya R. Rapidly reversible visual loss in posterior reversible encephalopathy syndrome: An ophthalmologist's enigma. Oman J Ophthalmol 2015;8:211-2

How to cite this URL:
Sachdeva V, Garg R, Pathengay A, Chandrasekharan A, Kekunnaya R. Rapidly reversible visual loss in posterior reversible encephalopathy syndrome: An ophthalmologist's enigma. Oman J Ophthalmol [serial online] 2015 [cited 2020 Jul 2];8:211-2. Available from: http://www.ojoonline.org/text.asp?2015/8/3/211/169886


   Introduction Top


An 18-year-old female presented to our clinic with sudden onset decrease of vision in both eyes 10 days postpartum. She complained of headache and was irritable. Her best corrected visual acuity was hand movements close to face with an accurate projection of rays. Her anterior segment was normal. Extra-ocular movements were full. Pupils were briskly reacting to light and fundus examination was normal in both eyes [Figure 1].
Figure 1: Color fundus photograph of the patient showing a normal fundus

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Visual evoked potential showed extinguished response [Figure 2]. She was advised magnetic resonance imaging (MRI) brain which showed presence of multiple round to oval lesions which were hyperintense on the T1-, T2- and fluid attenuated inversion recovery (FLAIR) weighted images in the posterior parietal, temporal and occipital lobes and cerebellum [Figure 3],[Figure 4],[Figure 5][Figure 6]. Corresponding diffusion weighted scans did not show the presence of a corresponding restriction suggesting cerebral edema. A diagnosis of the posterior reversible encephalopathy syndrome (PRES) was made. Patient's antenatal, natal and postnatal periods were uneventful. It was decided to observe the patient and patient had a spontaneous recovery of visual acuity to 20/20 over 3 days.
Figure 2: Visual evoked potential of both eyes of the case showing bilateral extinguished pattern but reproducible flash visual evoked potential suggestive of visual pathway lesions

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Figure 3: Axial T1-weighted image of the magnetic resonance imaging brain showing the presence of the hyperintense lesions suggestive of edema in the bilateral occipital and temporal lobes (white arrows)

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Figure 4: Axial fluid attenuated inversion recovery weighted image of the magnetic resonance imaging brain showing the presence of the hyperintense lesions in the medial temporal lobes (white arrows)

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Figure 5: Axial T2-weighted image of the magnetic resonance imaging brain showing the presence of the hyperintense lesions in the cerebellum and medial temporal lobes (white arrows)

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Figure 6: Diffusion weighted scan of the magnetic resonance imaging brain showing no restriction of diffusion suggestive of lesions being vasogenic edema rather than infarcts

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   Discussion Top


PRES is characterized by neurotoxic manifestations such as headache, visual disturbances, aphasia, facial numbness, seizure, and ataxia.[1] It results from the edematous lesions of the central nervous system and brainstem, especially parietooccipital lobes. These lesions result from a disruption of the cerebral perfusion auto-regulation leading to a vasogenic cerebral edema.[1] The presence of blood pressure fluctuations, toxemia of pregnancy (eclampsia or preeclampsia), connective tissue disorders, systemic inflammatory response syndrome, medications may lead to this condition.[2],[3] The characteristic MRI findings of T2 and FLAIR hyperintense lesions that may take three patterns (holohemispheric watershed, superior frontal sulcus or parietooccipital).[2] Visual disturbances are common and usually resolve without a permanent deficit. The ophthalmologists and radiologists should be aware of this condition to diagnose and manage patients.

Financial support and sponsorship

Hyderabad Eye Research Foundation, HERF, Hyderabad, Andhra Pradesh, India.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Walia HS, Grumbine FL, Palejwala NV, Sawhney GK, Risner DS, Walia SS. A very rapid visual recovery of posterior reversible encephalopathy syndrome. J Clin Imaging Sci 2011;1:36.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Bartynski WS, Boardman JF. Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol 2007;28:1320-7.  Back to cited text no. 2
    
3.
Bartynski WS, Boardman JF, Zeigler ZR, Shadduck RK, Lister J. Posterior reversible encephalopathy syndrome in infection, sepsis, and shock. AJNR Am J Neuroradiol 2006;27:2179-90.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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