Optometrists are adept at recognizing the most common patient complaints before we even bring the patient to the slit lamp. Dry eye disease, ocular migraines, posterior vitreous detachments—they all come with telltale signs.
But what happens when a patient’s symptoms lead us down the wrong path? The screentime and exposure to artificial light that life in the 21st century entails—and the new consequences of such exposure—can lead to some challenging case presentations.
There may be an impulse to go on a hunt for an obscure solution if your patient describes a misleading symptom. Don’t fall down that rabbit hole. Stick to Occam’s Razor and contextualize your examination in the 21st century.
A CASE OF PAIN AND PRESSURE
Some optometrists are more comfortable referring a challenging case to an ophthalmologist than to another optometrist. For some patients, however, referral to another optometric practice is exactly what is required.
A 41-year-old Asian man was referred to our clinic by another optometrist with complaints of pain and pressure behind his left eye. The patient presented to the referring doctor’s office as a new patient emergency visit for acute pain and discomfort in that eye. The patient noted “vision distortion” in that eye, which he described as a “swirling of vision,” typically occurring in the middle of the day or in the afternoon and lasting for several hours at a time.
Examination and History
His UCVA was 20/20 in both eyes. The patient never wore glasses, per his referral notes. The referring doctor found normal ocular health on dilated examination, and IOP was 16 mm Hg in each eye. Tear breakup time as measured by the referring optometrist was 8 seconds OD and 7 seconds OS, and the patient was placed on artificial tears four times daily in each eye.
The patient was referred to my practice for visual field and OCT testing of the optic nerve and macula to rule out other causes of pain and transient vision distortion in the left eye. On presentation to my clinic, after using the artificial tears for the past week, he reported no improvement to his sensations of pain and pressure around the left eye.
Testing performed at my clinic yielded normal results: No defects were observed on 30-2 Humphrey visual field analysis in either eye, and OCT imaging of the optic nerve and macula showed normal anatomy. IOP was 15 mm Hg in the right eye and 17 mm Hg in the left eye. UCVA was 20/20 in each eye, as it had been at the referring doctor’s office. Upon reviewing these normal results, I asked the patient for a deeper case history.
The patient reported using a three-screen computer monitor setup at work, with two large monitors flanking a small laptop positioned closer to him. His pain sensation and left eye distortion occurred only on work days and did not happen on days when he was out of the office.
Diagnosis and Treatment
With this information in hand and considering the patient’s age, a refraction was performed, revealing the true culprit: low uncorrected astigmatism and early presbyopia. A prescription of plano with a +0.75 add OD and plano -0.50 x 085 with +0.75 add OS was trialed in office. The patient reported feeling that pressure in the left eye was immediately relieved when the spectacle correction was trialed.
Uncorrected astigmatism, even when mild in nature, can cause significant subjective vision complaints. Extensive computer use may be factor; when it is, it may be termed computer vision syndrome. Symptoms of computer vision syndrome include headache, eye strain, double vision, watering, dryness of eyes, accommodation problems, tired eyes, and irritation.1 Symptoms may appear severe to the patient: one study found that 72% of patients with computer vision syndrome presented to their doctors as emergency visits with acute symptom complaints.2
In this case, a thorough case history was key to understanding the source of discomfort, as the patient’s symptoms coincided with prolonged device use. Even in patients with 20/20 vision, a refraction may be as effective a diagnostic tool as an advanced imaging platform.
A NEW-AGE CULPRIT FOR VISION LOSS
During the course of a comprehensive eye exam, it’s not uncommon to hear complaints of unusual and subjective visual disturbance when you ask a patient at the end of an otherwise normal eye examination if there are any additional questions or concerns.
At the conclusion of a comprehensive exam of a healthy 57-year-old black woman, the patient reported that sometimes the vision in her left eye “felt dimmer” and “less bright” first thing in the morning; her right eye was unaffected. Vision in her left eye returned to normal within 10 minutes of waking up or by the time she ate breakfast. This dimming had occurred approximately once every few weeks for the past 6 months. The patient reported no blacked-out vision.
Examination and History
Her BCVA was 20/20 OD with -6.00 -0.25 x 110 +2.25 add and 20/20 OS with -6.50 -0.50 x 090 +2.25 add, stable from her usual prescription. IOP was 16 mm Hg in her right eye and 17 mm Hg in her left eye. All ocular testing was normal, with cup-to-disc ratio of 0.30 and round cups in each eye. No evidence of optic nerve or retinal edema was observed. The patient had equal responses in both eyes on red cap test. Pupils were equal, round, and reactive to light and accommodation. Vascular and retinal health appeared normal, and the patient had no reported health issues. Humphrey visual field testing also revealed normal findings.
Further discussion of the patient’s lifestyle revealed that she often read on her phone before bed, lying on her right side and holding her smartphone in front of her left eye.
Diagnosis and Treatment
The findings in this patient are consistent with reports of transient smartphone blindness, described in a 2016 case report published in The New England Journal of Medicine.3 The report described two female patients who presented to a neuroophthalmology clinic with complaints of transient monocular vision loss. In both cases, all bloodwork and imaging were normal. Thorough case histories revealed that the symptoms occurred only on mornings after the patients had used their smartphones before bed, lying on one side and in a dark room. The symptoms were always on the eye contralateral to the side on which the patient had been lying. The feeling of dim vision or blindness in the one eye the next morning was due to differential bleaching of photoreceptors, with the eye viewing the smartphone becoming light-adapted and the eye against the pillow remaining dark-adapted.
After discussing this phenomenon with the patient, she was instructed to have the room lights turned on and not to lie on her side when using her smartphone at night, and to avoid using her smartphone right before bed. A phone call follow-up a few weeks after her examination revealed that these lifestyle changes resulted in resolution of symptoms.
TECHNOLOGY AND VISION
Technology has changed the way we all live: We can order a car to take us to dinner (or order a car to deliver dinner) and reconcile the tab with the tap of a screen. Still, the downstream effects of technology are yet to be fully realized. With the case descriptions above, readers are aware of at least two eye conditions that can be the product of our modern era.
- Reddy SC, Low CK, Lim YP, et al. Computer vision syndrome: a study of knowledge and practice in university students. Nepal J Ophthalmol. 2013;5(2):161-168.
- Al Rashidi SH, Alhumaidan H. Computer vision syndrome prevalence, knowledge and associated factors among Saudi Arabia University students: Is it a serious problem? Int J Health Sci (Qassim). 2017;11(5):17-19.
- Alim-Marvasti A, Bi W, Mahroo OA, et al. Transient smartphone “blindness.” N Engl J Med. 2016;374(25):2502-2504.