Dizziness and Visual Loss

Case 1 72 year old with vision problem

HPI 72 y/o man 4 months ago found to have squamous cell CA of lung. 3 days ago he had lung surgery. Yesterday he developed a "vision problem".

Exam by internal medicine resident and MSIII. Fundus exam shows bilateral cataracts, retinas appear normal. CN normal except "temporal deficit" in L eye, normal R eye visual field, and bilateral hearing deficit. Rest of exam normal.

Labs none relevant


  • 1. What is the location of a lesion that could cause this deficit?

Case 2 67 y/o with CC falling

HPI 72 y/o woman with history of intermittent atrial fibrillation, hypothyroidism, R knee replacement. Yesterday AM tripped in the bathroom, fell, hit her right shoulder. Afterward had headache right forehead, "blurry vision, can't focus", mild disorientation. She denied dizziness but may have had heart palpitations at the time she fell.

Medications ASA 325 mg/d

Exam BP 214/90, pulse 90, regular. Heart no murmur.

Neuro exam Mini mental state exam score 30/30. Visual acuity 20/40 on the left, 20/30 on the right. Rest of neuro exam normal according to neuro resident, internal medicine rotator and MSIII.

Labs Head CT normal.

Initial DDX

  • 1. Temporal arteritis (headache, visual changes)

    2. Hypertensive encephalopathy (high blood pressure)

    3. TIA (atrial fibrillation by history)


  • 1. Is this enough information to form a diagnosis?

Case 3 25 y/o with R visual loss

HPI 25 y/o woman 3 days ago developed "blurry" vision R eye. Involves vision just R eye, worsened for a day, now stable. No other symptoms, no prior neurological problems.

Exam EOMs full, no nystagmus. PERRLA, but R pupil dilates with swinging flashlight test. Fundi are normal bilaterally. Visual acuity 20/200 OD, 20/30 OS with near card. Rest of exam normal.


Visual evoked response shows P100 latency Left = 105 ms, Right = 120 ms.


  • 1. Where is the lesion?

    2. What is the most likely diagnosis?

    3. What other tests might you like to do?

Case 4 24 y/o with L eye visual loss

HPI 24 y/o woman in Nov 2005 noted decreasing vision left eye. This gradually worsened to involve more and more of the L visual field.

Exam January 2006. Visual acuity 20/20 OD and 20/20 OS. Confrontation visual field testing shows in OS only L temporal deficit with central sparing. PERRLA, swinging flashlight test negative. Rest of exam normal.


  • 1. Where can a lesion cause this deficit?

    2. What is the etiology?

Case 5 40 y/o with dizziness

HPI 40 y/o man developed intermittent dizziness one month ago. Precipitated by turning over in bed, head movement. Feels like the room is turning. Mild nausea. Hit his head on a cabinet a few weeks ago.

Exam Cranial nerves all normal. No nystagmus, coordination good.

Hallpike test No symptoms with head turned to left. With the head turned to the right, then with a one or two second delay, develops torsional nystagmus and vertigo, lasting several seconds, then subsiding. Symptoms recur on sitting up.


      • 1. Where is the lesion?

        2. What is the diagnosis?