SAEM Clinical Image Series: Double Vision

Chief complaint: Double vision

History of Present Illness: 61 year old female with history of HTN, DM, hyperlipidemia, and chronic low back pain presenting with double vision. She received an epidural spinal injection yesterday for the 4th time for low back pain. She was sedated for the procedure and woke up with headache, neck stiffness, and left eye “jumping around,” which progressed to double vision 1 hour later.

There was no blurry or double vision with either eye closed. She had 1 episode of emesis. She presented to the ED 24 hours later with continued headache and double vision.

Physical Exam

General: Well-appearing, no acute distress

Eye:

PERRL
Right eye: Ptosis, mydriasis, and limited elevation, adduction, and depression of eye; no relative afferent pupillary defect
Left eye: Normal

Cardiac: Normal S1, S2; no murmur

Pulmonary: Normal chest excursion with respiration; lungs clear bilaterally

Abdominal: Soft non-distended, non-tender

Neurologic: 5/5 strength bilateral upper extremities and lower extremities; sensation intact; finger to nose normal

Laboratory Data

CBC: WBC 12.4, Hgb 13.4, platelet 222

BMP: Na 138, K 4.5, Cl 100, CO2 24, BUN 19, Cr 1.0

Thyroid function tests: Within normal limits

Case Question: What is the neurologic deficit? What do each of the images show?

Right cranial nerve III palsy

Image 1: Leftward gaze demonstrating incomplete adduction of right eye and ptosis noted to right eyelid. There is also mydriasis although it is not clearly shown in the photo.

Image 2: Upward gaze and demonstrates incomplete elevation of the right eye.

Image 3: Intracranial air anterior to brainstem (pneumocephalus)

Case Question: What is the explanation of the patient's presentation?

Pneumocephalus after epidural injections is a rare complication of a common procedure. Only a few cases are reported per year.

Unintentional dura puncture causes air to be introduced into the subarachnoid/subdural space and migrates intracranially, and may cause a headache. It is possible that there is cranial nerve III compression as it exits the brainstem.

Case Discussion

Take Home Points

CN III palsy can present with the following:
- Ptosis
- Dilated and poorly reactive to nonreactive pupil
- Paresis or paralysis of ocular adduction, elevation, and depression.
Pneumocephalus is a rare complication of epidural injections.
Treatment of pneumocephalus may include 40-100% oxygen and admission for observation, if symptoms are severe.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.

Author information

Richard Wang, MD

Resident
Emergency Medicine
Maimonides Medical Center

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