To the Editor:
An 85-year-old woman with no significant past medical history presented after a mechanical fall complicated by multiple fractures. She received intravenous pain medications with resultant decreased level of consciousness and respiratory distress. Intubation was difficult because of bilateral mandibular fractures, and she consequently experienced 10 minutes of hypoxia before secure airway control could be established. She underwent surgical repair of her mandibular fractures and required tracheostomy placement. The patient was initially neurologically intact, but on hospital day 5 the patient complained of blindness. There was no report of seizure activity, fever or chills. Her vital signs remained stable. On examination she was noted to not be able to fix her gaze and did not have optokinetic nystagmus. She could not perceive colors or shapes, but the remainder of her neurologic examination was normal. A clinical diagnosis of cortical blindness was made. Ophthalmology consultation concurred with the diagnosis of cortical blindness. Basic laboratory testing, including infectious workup, was unrevealing. An electroencephalogram that was done during her hospitalization did not reveal any epileptiform discharges but had generalized moderate slowing suggestive of encephalopathy. Magnetic resonance imaging of the brain revealed curvilinear bilateral occipital T2/fluid-attenuated inversion recovery sequence hyperintensities (Figure A) with corresponding restricted diffusion on diffusion-weighted image sequence (Figure B) apparent diffusion coefficient sequence (Figure C). On hospital day 12 the patient reported improvement of her vision and was now able to identify colors and shapes.
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-Kaustubh Limaye, MD, Ashutosh P. Jadhav, MD, PhD
This article originally appeared in the September 2017 issue of The American Journal of Medicine.
