Journal of Neuro-Ophthalmology, December 1981, Volume 1, Issue 4

Movement phosphenes in optic neuritis.

}. C!in. N~uro-ophthdlmol. 1: 279-282, 1981. Movement Phosphenes in Optic Neuritis MARC A. SWERDLOFF, B.A. ALlE ZIEKER, M.D. GREGORY B. KROHEL, M.D. bstnct P~tients with optic neuriti m,J nole bright-colo~ fbshing lights upon enlry into ~ (Luk room, a.nd lhese movement phosphen m~ ~ ~ggnY~led b horizon­bl eye mo ements. Thrft p~tienl.s wilh thi.s phenome­non Me described. It m,J be.n irrit~tivesymptom in the optic nerve ~alo ous to Lhermitte's sign in the pinal cord. The differenlial di,Jgnos1S of "fbshing lights" i presented. In 1976, Davis et .11. noted an association be­tween e. e movement-induced positive visual phe­nomena (movement phosphenes) and optic neuri­tis. 1 Since that report. no further mention of this interesting phenomenon has appeared in the liter­ature. It i the purpose of this report to present three additional cases involving movement phos­phenes in optic neu ritis, review the differential diagnosis of "flashing lights," and suggest possible mechanisms for their appearance. Methods and Materials Patients seen within the last year with optic neuritis wer asked whether they had noted "flash­ing lights" prior to, during. or subsequent to the onset of their disease. For the purpose of this study, the patients were contacted by telephcne in an effort to update and confirm the information con­tained in our records. Twelve patients with optic neuritis were seen, and th ree reported "light flashes" during or after the onset of optic neuritis. Case 1 A 25-year-old woman complaining of decreased visual acuity in the right eye first noted an acute loss of vision on the right side in 1977. The visual acuity was light perception in the right eye and 20/ 20 in the left eye. The acuity in the right eye From the De~rtment of Qphth..lmology. Alb..n Mfilic..1Col­lege, Alb.any.' Yo.. December 19 1 improved over v roll w eks to 20/30. There was a recurrent los of vi ion in the right e e in August 1978 with the visUAlI acuity at that time dropping to 20/200 in the ri ht eye. i ual acui in the nght e e returned to 20/ 0 in September 1978. In Feb­ruary 1978, the patient hdd visual-evo ed poten­tials, which reveal d a conduction deldy on the right side only. The patient was seen in consultation on April 2, 1980. because f loss of visual acuity in the right eye associated with pain on e e movement. She had noted decreased vision in both eyes during strenuous e ercise for the PdSt ear. isual dcuity was 20/70 in the right e e and 20/30 in the left eye. 0 afferent pupillary defect was seen. On visual field testing. bilateral central scotomdS were noted. Mild opti atrophy WdS seen on the right side, but the left di c ap?eared normal. It was felt that the patient had bilaterill optic nc?uritis clinically evident on the right sid.? and relatively asympto­matic on the left. A neurologic examination was completely neg.Jtivc. A skull series with optic canal views was found to be within norrodl limits, and computed tomography with a fourth generation scanner reveal d thinned and attenuated optic nerves bilaterally. A spinal tap. in luding protein and IgG levels. was normal. The visual acuity gradually improved to 20/40 in the right eye but remained at 20/30 in the left eye. In the following months, the patient began noting bilateral attdcks of complete amaur i fuga . Most of these amau­rotic 3ttacks last d only minutes, but occasionally would last for sever I hours. Neuro-ophthalmolo ic e amindtion in February 1981 revealed a correct d visual acuit of 20/30 in both eye. There wa bildterdl peripherdl isual field constriction in njun ti n with bibteral cen­tral .lnd arcuate toma. Ther \Va diffu_e drop­out of the n rve fin r layer in both e . The patient reported or the first time that she noted cGlored flashing light in both e es when in a d.ark room during the past everal months. They were frequent I associated with eye movement. She de­scribed the Aa hin Ii hts as resembling images seen when "looking through a kaleidoscope," start- 279 M.,y('m('nl I'tw~ph('n('s ill Ur1i, N('ufltis in~ in thl' cl'ntral fil'ld and movin~ to tht.' periphery. Thes(' were not olssm'iolted with hl'adJche, nJusea, l.\r vomiting. Thl' l'pisodl's of flashing li~ht usudlly IJsted 11'5s than t minute. Rl'~Jtl'd n('urologic ('\.\min.ttion W.IS C'nlirl'ly normal t'xc('pt for the \lphthJlrnologi, findin~s. Subs<,quently shl' com­plJin(' d of mJrked f.ltigue, which W.lS E'x.lcerb.lled !;ly t.lking ol hot show('r, Cast' l A Jb-YE'.Jr-old whit(' womiln presentl'd to her locdl ophthillmologist with a complaint of blurred vision in her left eye. The blurred vision had come on Jcutely I week prior to this examinJtion. Thl' pJtient hJd noted blurriness and WJvy lines in the lower visu.ll field of the left eye which progressed centrally, milking it difficult to perceive colors or leiters. She also had noted the simultaneous onset of J dull pain in her left temple, numbness of her left forehead, left cheek, and in back of her left eJr. Her visual acuity at that time was 20/20 in th(' right eye and 20/40 in the lefl eye. The pupils were equJI and reacted normally 10 light and a near target. A left afferent PUpillolry defect was ilppar­ent. There was a slight decrease in adduction of bolh eyes ilnd slowing of saccades on adduction, consistent with a mild bililteral intemuclt'ar ophthalmoplegiil. Fundus examination was normal. Visual field testing was normal in the righl eye but showed a markedly constricted visual field in the left eye with a dense inferior arcuate scoloma. There was a decreased corneal reflex in the lefl eye. There was decreased sensitivity to pinprick on Ihe left forehead and lefl cheek. Neurological ex­amination was olhenvise normal. The patient was felt to have retrobulbar neuritis and probably de­myelinating disease. Three days later she was Jd­mitted to the hospital because of persistent pain and decreased vision in her left eyt>. Blood chem­istries were within normdl limits. Electroencepha­logrilm remained normal during intermittent photic stimulation and hyperventilation. Skull x­rays with views of the optic canal were normal. Cerebrospinal fluid analysis was normal except for a total protein of 50 mg/dl (normill = 15-45 mg/ dl) and dn IgG component of 14.5% (normal < 14%). The patient WilS started on d la-day c(lurse of ACTH, and her pain subsided within several ddYS. She WdS disch,nged with J visuJI olcuity of 20/40 in the I('ft eye. One month Idtef she noted left ('ye polin !;lut no fu rther fdcidl hypesthesiols. Her ophthollml11(lgic ex­dmindtion WdS uncholnged. ShE' WolS stolrted on a short course of high-dose prednisone (100 mg td­pered to 10 mg in 18 d<lys). Two weeks later the pdtient noted improved vision, olnd her visUolI .1.cu­Ity in thC' left C'yC' Jt th.1.t time me.1.sured 20/25. rWll III"nlh... 1.111'f. IlIl [uly 22, IQflO. the poltient was seen in consultation ilt the Albany Medical College because of increased difficulty in judging distances and in viewing moving objects. It was at this time that she first complained of flashing lights when she entered a dark room. The lights were alway!> associated with horizontal eye movements dnd were described by the patient as diffuse, flash­ing, colored lights occupying the whole visual field of the left eye. On careful questioning, it was discovered that Ihis phenomenon had been present I week after the onset of the inilial decrease in vision Examination revealed a corrected visual acuity of 20/20 in both eyes. There was a left <lfferent pupil1i1ry defect. Visual field testing re­ve< lled an enlarged blind spot in the left eye. Ophthillmoscopy showed slight optic atrophy and thinning of the left inferior temporal nerve fiber l<lyer in the left eye. Visual-evoked potentials re­veil led <l milrked conduction delay in the left eye. The right eye was normal. The impression <It that lime WdS retrobulbiiT neuritis with good recovery. The difficulty experienced with moving objects WilS thought to be due to the conduction del<lY in the left eye, causing a distortion of objects in molion, viz., the Pulfrich phenomenon. The eye movement-induced "fJ<lshing lights" were thought to be movement phosphenes associated with optic neuritis. Six months later the patient reported intermit­tent eye polin and blurred vision when she WdS fdtigued. Her neurologic examindtion hilS other­wise remained normal. Case J A JO-yeM-old man compl<lined of experiencing bililt('ral orbital pain for 10 days. the left side more painfulth<ln the right side. The polin was constant .1.nd aggravilted by eye movement, especially ex­treme I.:-ft gdze. Horizontal diplopid WilS also noted on extreme left gue. There was no complaint of visudl blurring or visuillloss. On examindtion on Jdnudry IS, 1981, the ViSUdl <lcuity was 20/20 in each eye. There was no con­junctival injection or proptosis. The pupils were normill. <lnd no <lfferent defect was noted. There was a slight decrease in abduction of the left eye. The remJinder of the ophthalmologic examination WolS norm.1.!. including visual field testing with a tdngenl screen and Goldmann perimeter. Neuro­logic examiniltion was .lIsa normal. Complete blood count and sedimentation rate w('re normal. Roentgenograms of the skull and computed tomography of the orbits, plain and enhdnced, were normal. Three days dfter the initial examination the pa­tient noted central blurring of the left eye. Visual ilcuity WilS noted to be 20/15 in the right eye and 20/20-2 in the left eye. He experienced showers of joum<ll of Clinical Neuro-ophthalmology fl.bhin~ whitt' li~hl'; lIl"'11 t'l\h'ril1~ .1 d.,r" r""IlI, whid1 Wl'ft' ilh'r",I~"d hy o'y,' n"wo'I1H'nl Vi~lI.r1­e\' l'\..".:! po'tl'l\li.ll~ H'\'l'.llt-d bdr,h-r1int, l.,tt'lll lo'~ III [>.,th "\,,,~, ,md ,1 di,I~Ill'~i~ "I rt'!I\lbulh.lI IH'urill'" ""1~ 1I1.1dl'. Thl' "Ii~hl Il.l~Ilt'~.. dlrnll1i...lwd .I~ tIlt' P,llit'nt'~ ,·i~'l.Il.l\llity ~r,ld\l,IIJ\' rl'1urtlt'd t., III'rlll,11 .'\'l'r 11ll' t'n~"in~ " W"t'''''' Discussion ~h,\"t'nH'nt I'lh'~l'ht'lw~ W\'I',' Ih.t,·d in "... ~,,, LI­ti.' ll wilh .'pti( nl'llrtll~ iI' .111 Ihn',' 1',lll.·nl .....,1· llwu~h tIll'\" wo'n' Ih'l ft'p.lrt".l .lurll1).; tIlt' illlli.11 .llt.h·"~ .'1 lilt' ,lr~\'.l~'· :\11 Ihr.... p.lti,·nh IH,lt'.l th.. rlh'\"t'I1ll't\l I'h"~I'IH'II\'~ "I1it' \\,h.. n till'\' 1\'I'r.' In .1 J.H" r,\.'1Il In ,Id.liti"ll ..llIthr"t' 11<>h',j., r"l'l\"hl" Iblt' "\,I(t'rb,'ll.'n .'1 th.-I r I'h"~l'h,'n.·~ ,m "Y" m.'\""· rlh'nt Tht'rt' \\',l~ Ill' .1pl'.lft'nl rt'l,lll"ll~hll' b,'II."t'l'rl th" .lpp,',H.lr1(o' .,i llh'vt'nWIH I'lh'~pht'l\l'~ ,1I1d Iht' Jq~r"" .,f \'i~1I.11 Jy~fl1n(li,'n durin~ till' .Ilult' ph,,~t' <'I .'ptl( Ill'\lritl~ Alllhft'., p.lti(·nl~ h,l.I.1 ~ignifi(.l11l rt'lurn .,f \"I~u.11 lundl"Il. whi(h indl.-,It"", t., II'" th,lt m"\"l'nwnl ph,'~ph"lll'~ "r,' 11.'t .111 .'rnin"115 ... i~n. Our frndlll~~ .Hl' .-.'r1"'I~ll'nl wilh th""e rep.,rled by DJ\'i" et .11. 1 They Tl'\'i,'\\,eJ nin.. p.,til'nl", wh., ("mpl.lineJ "f m.wenwnl ph""phenes .mJ (Jni('d .1 JiJ:o:,n"';'ls .'1 ,'rli.- neunlis .md/,'r mullipl(' ,;,d.,· r"SI" Their p,llienl" I\'('r(" similJr It' .,ur~ In th,ll light fIJ~h(>" \\'er" usu,llly ,l((elllu,!l".:! by hnriz"n· toll eye m.wemenl in ,I dM" w.'m, In lh("ir ~,'ri(>",. "1\ pJtlenls Iwll'd m".'ement phl,sphene,;, Juring the Jcute pholse I,f Ihe opti( n('uritis. while 11\'1' pJtients rep.'rled them subsequent ttl tht> ,Kut,' phase. One p.llll'ol reportl'd movement ph.,,;,­phenes durio~ lhe active ph,lse of multiple sclero­sis. JIthou~h thert' \\'.1<' no definilive (IiniC,ll evi­denc(> of oplic neurilis,lt the lime, Phosphene" produced by suddeo movements .,f the eyes (movemenl phosphl'rws) \\,,'ft' de..., rib,'d as early as lBIQ by Pur"IllW," l.,inll· Ih"n. nltw('­mel'll phosph"nl's hJv(' b"('11 11"1<'J tll lltt IIr in individuJls With norm.11 vl~lt>n wlwn Ih,' I'y\' i" placed <It thl' extreme limll~ tlf h••rizont,ll. v('rtil.ll.' or convergent gaze.' Davis et .11. n><;tolt(>d Iholt mllV(>m('nt ph"~rh"IH'''' may be lhe vlsUJI "qulvJleol of Lhermltlc'" <;ign Patients wilh Ihis sign cnmpl.,in .>f "h","-Ir",· I'M· esthesias in Ihe trun k Jnd/"r ('x1 rem it iI'" .Ift .. r r.lpld flexion of the ncck. It i~ ~een in .I~"tlti.lli"n wilh multiple sclerosi<...llthough thl' l'\,ld l'li"l"gy rl'· mdins unclear. [),lVi~ 1'1 .11 P""I\ll.lll'J th.lt Lht·r· mille's sign might bl' pr"dun'd by Ih[' nwrh.\Ili •.11 deformalion ,1nd firing tlf nerve ,IX"I1~ Ih,ll h.ld become hyperexcitJble "enmd.lry 10 dellly,·lin.l. lion. Similarly. mOVl'ment ph,,~ph{,rlt·~ In.ll' L... tilt' result of eye movernenl-indlKed met·h,IIlI'·.ll dd"r· matioo dod firing of ,m upti, n{'rvt'lh"t h"d bt·. ,'Ull' hyperexcilable secondJry hI J ..myt·lin.,ti'.n. Lhermitte's sign is olisu seeo io ,I"",,,·i.,ti\'n with Deccmber 198t '-,\\,,·,.11,.11. 1.1"""f. "",Iwl ~1'1I1.,1 1,'rJ ""l11l'rt'""i"n "ynJwIlH's. I',~.. tt·rvi\.11 ~1l<>l1dyl,,~i~ .. 1"I1'\!"n of Ilw 11('\ k in thl' 1'T(·...enc'· "I ,,'rviL,1 ,.111,11 "t('n"~i,, rnmrnllni,,('" the c"rJ "'111'...I.lllt .'~ I,l' din', I Ill." 11.,n i•.11 ., .n,pr,·""i, ,n. pr,.· .lll< ill~ till' I h.lf.1t 1l'fi"ti. 1'.ITt·"th'·"I.l'" of l.Iwr­111Itte'~ ~ign, Wlwllwr .l('myt·lin"tion pL1Y" ,I r,,!r· in tlH' 1'.,th"g"llI'~i~ ,,' I.h"fIllillt'·" "ign in Ihi~ .lini•.II ...dtil1g i" llI.t "n"wl1 I{t·g.lrdl.·~.... 111"oh.1n· Jr,11 dd'\I'I1\,11Ion "I Iwrvl' hun.:!II·....IPI,,·.1T~ tI, b.. till' '''111111\'11 dl·l1olllil1.1h,r In Iht· I'ro,du,li"n "f lIll'flllitt.. ·... ~igll .111,1 it" ," ul.lr I·<.juiv.,lt-nt. rnovI'­1111' 111 ph"~l'h"Ill"~, TIll' dilll'rl'l1ti,II,li.l).;n""i" "IW (on~iJ"r" wlll'n ,1 ".1111'111 ,ornpl.lin" "f f1.1~hin~ Ilghl~ nm1l11"nly in· d ud('~ tld,lt hnwnl I,f till' retinol," po~!('ri"r "11 r('ou~ dd,lthnWlll wilh vitreordin,lltr,lclino.· the ,>,intil· I.ltin~ ".-"lorn,1 "f migr,lin,,: ,lIld blunt f"r«(' l,r Jecp pres~ur".lppJied 10 the eyebJl1 ' les" (11mm"n c.1\lS('S .,f fl.lshin~ li~hts include Ih(' JppeJrJn(C' of s(intill.ltio~ s,,,lomJ without mi~r"ine'" JrlC'riove­I"' U~ m,llform,llitlll of Ih(' I'ccipil.ll lobe. I" lesi.'n~ of the p,Hietl'tempor.11 re~ion.'1 olnd retinal mi· rr"(,l11b.,li." Ophl hJlm"lo~i~ts<;hl'uld incluJf' .)ptic n('urilis in Ih"ir difh'rentiJI di,'~l)llsi~ I,f ··fl.l",hill~ lignh:' "~p.,..ioll1y in the c1iniCII selling Ji5(U",Q,J Summary Movement ph,'",phene", \V('T(" noted in thr(',' .,f I::'. p.lIiellh wl1<> pre5enleJ Within 111<' 1.1~t "{'.If With ,Iptic n('urili5. Th" l11,lVellll'nl I'hl'sph('IH'~ \Ven' dl'scribed .15 bright. (olt'n'd, fl.l,;,hll1~ II,I;hl,;,. whlrh ocrurr('J only Upl," entry illtn ,I d.If" r.'''1ll .Hld wt>re fr('quenlly J~~r,lV.lled by h.lfiz.lIll.ll ey(" m(lVemenl. Movement ph.,sphell('';' .1f{> ,I ~i~n "f ,'pli, neurilis ,llld ,;,lwulJ be (.'n~iJ,'re.l III th" diffcrenli,ll di.l~nl'sis I,f ··fl.l,;,hlll~ II~hl~.· Itt'ferenccs I\"'I~. I ,\.1"'1').;"11. I) :--,h.,"'. { tll.Il,'".lld I .mJ I)"lll~.h. \,v tl·1t"·"I11'·1l1 I'h'''I,lw,ll'~ ,,' "1'(,. n.·,,,,tl', N"I1I""/".>:.I' .!e-: 11(10-1 1l1-1. 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I"', .!81 /l.l",·o·"ll'nl l'h''''I,II<'''''~ .,,1 JI'I" N.·., •• t.~ l.yr.to·I", r"p'1I\'~ ,,, 0, L,l'",cory 8 K,ohrl, DrP'lft, /11"111 "f l )rhth..lm"t,')(v, Albolny MWICJI lollp):t'. ,0\1­I.. mv. :x...... Y..,k 1;!2011 Acknowl~dgm~nls Th... p.lfX"r "Yo!' "upro:,rt"d In Polrt by T',llmnjo; Gunl I YOiOJ7 fr"m Ihr NJI,,>nJlln~htult'!iof Hf'dlth, Noillon.ll I y" In~,lut,·. olnd o1n unrr-;!r.Cl('d X'JOI lrum r{f'!,{'.Irch '0 l'It'v"nt Hl,nd,,\...~ \'..."." 0.,,"",'1/1 l'Ill-e-. p .::NI " lV,I,·,· I~ (, 1'1", ~'II1"II.oll11~ .....h.m.l ",.Ih..,,! 1......1 ." I.... \",. (1""",.• llIu.1 II: !'.·II·:-:l... 1'1r'U Ih,,'~1 1 II ...,.1 N"wh'" I II (),,"I"I.,I 1,>1"'.11 " .... 'I n, '11~ n•.olt." '11.01" 'Il~ { 111m .01 .....1 ,.,.1" ,I,');" .1 I h·.II"" 11\ ;:(0 , ........ wolh • "nllllt'uh "" 11.,· .1.1t.·, "11".,1" .., I".m ""p.11110' .. \ .. I, I 'I .Io,Io••I"u,/ 01.\:;: ~l. 1";':- II {''):olll 11(. ,' ·Ul'oI.'" ,.,1/,.. ( 1I."l.... ( I h,,"' ,,!"IIl,,',,·!J III '"