| OCR Text |
Show © 1989 Raven Press, Ltd., New York Exercise- Induced Transient Visual Events in Young Healthy Adults Captain Richard K. Imes, M. C., U. S. N., and William F. Hoyt, M. D. Six patients with a variety of exercise- induced transient \' isual events are described. Each patient was in excellent health and most exercised regularlv. None of the patients had a history of migraine, and only one gave a history of migraine in the family. One patient reported a single event, and the others reported recurrent events. These recurrent visual events were stereotyped except in one patient who experienced two distinctly different visual phenomena. Two patients described classic scintillating scotomas. Two described flickering phenomena in the central vision. Three described monocular events: one reported central scotomas, another blurring in the temporal field, and the third reported amaurosis. In no case could it be established that these events were associated with underlying disease. We believe that exerciseinduced migraine equivalents are the most plausible explanation for these transient visual symptoms. Key Words: Transient visual events- Exercise- Young adults- Migraine equivalents. From the Department of Ophthalmology, Naval Hospital, Oakland ( RK. J.), and the Neuro- ophthalmology Unit, Departments of NeurologICal Surgery, Neurology, and Ophthalmology, the University of Cahfornla Medical Center, San Francisco ( WF. H.), California, USA Address correspondence and reprint n.' quests to Capt. R. K. Imes, Me, USN, Department of Ophthalmology, Naval Hospital, Oakland, CA 44A27- sonn, U. SA The op, nltJns and a" ertltJns exprl'" ed herein are those of the , juthl) r~ , Ind , He nllt tIl Qt' (.'( In--. trUl'd d .... otbClal ur d ..... necL'ssarily ' I , II · " r I, I" ~-, ' I'll ( II tht: Navv nf of the 178 A classic example of an exercise- induced visual event is Uhthoff's phenomena occurring in patients with chronic demyelinating optic neuropathy ( 1). Such patients lose vision transiently in one or both eyes from the effects of exercise or effects of elevated body temperature. In 1971, Fisher ( 2) reported a 56- year- old man who experienced episodes of bilateral altitudinal visual loss evoked by running, mowing the lawn, brushing a coat, or getting mad. He had bilateral occlusion of the internal carotid arteries. In 1988, Lessell and Kylstra ( 3) reported two patients who had unformed exercise- induced hallucinations in one hemifield. Both had tumors involving one occipitallobe. We report here the cases of six healthy young adults, without history of migraine, who experienced a variety of visual events precipitated by strenuous exercise. REPORT OF CASES Case One For 15 years, a 32- year- old ophthalmologist had observed small, central, spoke- like images immediately after prolonged strenuous exercise, such as playing basketball, swimming laps, and aerobics class. The images appeared to be red- tinged, pulsed at a rate of approximately 2/ s, and faded after 5 min. He could see normal detail through the images. He was in excellent health and did not have a history of migraine. Case Two A 37- year- old nephrologist noted a bright, central, bean- shaped scotoma after jogging 1.5 to 2 miles. The scotoma obscured his central vision, expanded slowly outward, and disabled him enough TRANSIENT VISUAL EVENTS IN YOUNG ADULTS 179 to make him stop running. After several minutes, his vision returned. He did not get a headache and reported no other symptoms with the scotoma. One month later, he experienced a similar episode, again while jogging. A neurologic examination was normal. A contrast- enhanced computed tomography ( CT) scan was interpreted as normal. In addition, he reported the regular occurrence of a central flickering or pinwheel sensation whenever jogging. These phenomena did not impair central vision and would fade after several minute5---€ ven when he continued jogging. He habitually ran 3 miles 6 days a week and was in excellent health. He denied having migraine headaches. There was a family history of migraine. Case Three A 36- year- old healthy optometrist noted abrupt loss of vision in his right homonymous field after performing 100 sit- ups. The edge of the scotoma had a rippling- wavy, bright grayish color. The hernianopic scotoma lasted 15 min, moved slowly temporally and superiorly, and then faded away. He did not get a headache or other symptoms with the scotoma. He was exercising, dieting, and taking diet pills containing phenylpropanolamine and caffeine. He had no history of migraine headache, and there was no family history of migraine. One year later, he said he had not had any recurrence of the scotoma. He still exercised but no longer took diet pills. Case Four A 15- year- old, 237- pound high school wrestler had recurrent blurring in the temporal peripheral field of his right eye after an hour or two of strenuous exercise. When he looked with his left eye alone, he did not see the blur. He said it was " like looking through water." His vision would clear after 30 min of rest. These events had occurred for 3 years, initially three to four times a week, then gradually decreasing to once every 1 to 2 weeks. He did not have headaches. There was no family history of migraine. A neuro- ophthalmologic examination was normal. When contacted 4 years later, he said he still had occasional episodes. He still exercised strenuously and was a collegiate rugby player. Case Five A 45- year- old aerobics instructor noticed she could not read her watch with her right eye after 20 to 30 min of aerobics class. She described a central horizontal band of dimness or " graying- out" that tapered at the ends. The vision in her left eye was normal. She did not get a headache or have other symptoms with this event. She did not have a history of migraine. A neurologic examination was normal. Over the next 4 months, she noticed the scotoma regularly with strenuous exercise and then gradually became less aware of the visual loss until she no longer experienced it. Case Six A 25- year- old weightlifter experienced three episodes of transient blindness in his right eye within a 3 month period. Each episode occurred after heavy lifting and straining. He described one episode that occurred after lifting a 180 Ib friend with back pain. He stood behind his friend, wrapped his arms around him, and lifted him several times to stretch his back. One minute later, the vision in his right eye began to dim, progressing to blindness in about 15 s. Two minutes later, the vision began to return, gradually brightening to normal over a minute. Evaluations by a neurologist, a vascular surgeon, a cardiologist, and a neuroophthalmologist were normal. A CT scan was interpreted as normal. An arteriogram was not done. DISCUSSION These six patients illustrate a variety of transient visual phenomena occurring with exercise. In each instance, the visual disturbance was the only symptom. None of the patients had an accompanying headache. None had a history of migraine and only one gave a history of migraine in the family. Each patient was in excellent health. Only one was taking medication; he was taking diet pills, dieting, and exercising to lose weight. These episodes occurred with a variety of physical activity including sit- ups, heavy lifting, and strenuous aerobic exercise. Their frequencies range from a single event to recurring stereotyped visual phenomena over 15 years. One patient experienced two distinctly different phenomena, one that occurred twice, and another that occurred regularly with jogging. We believe that exercise- induced migraine equivalents are the most plausible explanation for the transient visual symptoms in our patients. ] okl ( 4), in 1977, reported on exercise- induced migraine. He described it in himself, writing that, " During my freshman year in medical school, I ran the anchorman position on the mile relay team in the German track championships in lena. We won I Gin Neuro- ophthalmol, Vol. 9, No. 3, 1989 180 R. K. IMES AND W. F. HOYT by a small margin. I was then seventeen years old, and this was the first time I had been clocked in under 50 seconds. A few minutes after the race, my happiness over the victory was interrupted by nausea, headache, weakness, and vomiting. It lasted 15 minutes and quickly subsided." In a discussion on headache in sports, Atkinson and Appenzeller ( 4) stated, " Migraine may occur after exhaustive muscular effort of any kind, and tends to be more frequent at high altitudes." They reported that acute effort migraine occurred frequently in athletes at the Mexico City Olympics and that some athletes experienced only part of the syndrome. They noted that dehydration, hypoglycemia, excessive heat load, alcohol, and poor physical conditioning contributed to it. They cited the case of a physician who regularly developed attacks of homonymous hemianopia, but never headache, when skiing at 11,000 feet. There have been other reports of exerciseinduced transient visual events without headache. Finelli ( 5) described a 42- year- old black man with sickle cell trait who had experienced three episodes of monocular blindness during one session of intercourse. He was drunk at the time. Thompson ( 6) reported a 31- year- old man who had a scintillating scotoma 1 h after jogging. He speculated that the combination of the caffeine, hypoglycemia, and an unusually energetic work- out may have precipitated the event. Perhaps hypoglycemia and the effects of the phenylpropanolamine and caffeine in diet pills were factors promoting the migraine scotoma in one of our patients ( case three). Six of 61 men with transient visual disturbances believed by O'Connor and Tredici ( 7) to be episodes of acephalgic migraine noted their scotomas during or after exertion. These men were all Air Force flying personnel who were thoroughly evaluated. I Clin Neuro- ophthalmol, Vol. 9, No. 3, 1989 The central pulsating spoke- like images described in case one and the central flickering or pinwheel sensation in case two resemble the personal episodes described by Purkinje ( 8) in 1825 when he took digitalis. He called them " flicker roses" and stated that he had also had them after he had exercised. Friedman ( 9) postulated that Purkinje's flicker roses were entoptic phenomena caused by pulsations of the retinal vessels. Perhaps these also are migraine equivalents. We believe the exercise- induced visual episodes we describe here are more frequent than indicated by previous medical reports and that in an otherwise healthy patient they may be regarded as benign. Acknowledgment: The Commander, Naval Medical Command, Washington, D. C., sponsored this Clinical Investigation Program case report 89- 48- 1970- 99. REFERENCES 1. Uhthoff W. Untersuchungen uber die bei der multiplen herdsklerose vorkommenden augenstorungen. Arch Psychiatr Nen.' enkr 1890; 21: 55-- 116, 303- 410. 2. Fisher CM. Cerebral ischemia- less familiar types. In: Clinical Nfllrosurgery, Vol. 18. Baltimore: Williams & Wilkins, 1971 : 267- 336. 3. Lessell S, Kylstra J. Exercise- induced visual hallucinations, a symptom of occipital lobe tumors. JClin Neuro- ophthalmol 1988; 8: 81- 3. 4. Atkinson R, Appenzeller O. Headache in sports. Semin Neurol 1981; 1: 334---- 43. 5. Finelli PF. Sickle cell trait and transient monocular blindness. Am I Ophthalm( l11976; 81: 8S~ 1. 6. Thompson JK. Exercise- induced migraine prodrome symptoms. Headache 1987; 27: 2S~ 1. 7. O'Connor PS, Tredici TJ. Acephalgic migraine. Ophthalmology 1981; 88: 999- 1003. 8. Hanzlik PJ. Jan Evangelista Purkinje on disturbances of the vision by digitalis, one hundred years ago. lAMA 1925; 84: 202~ 5. 9. Friedman B. Observations on entoptic phenomena. Arch OphthalmoI1942; 28: 285-- 312. |
