A 28 year old woman complains of double vision.

Question Number 0009
A 28 year old woman complains of double vision. She explains that she has had three similar episodes over the past two years which have resolved spontaneously. Examination is unremarkable except for a generalised mild weakness of the extremities and a prominent nystagmus in the abducting eye that resolves on convergence. She is most likely suffering from
a) non-proliferative diabetic retinopathy
b) proliferative diabetic retinopathy
c) vitreous detachment
d) systemic Lupus Erythematosus
e) multiple sclerosis

Correct Answer: EMultiple sclerosis

The diagnosis of multiple sclerosis rests solely on a high index of suspicion. The main indicator are signs and symptoms charactersied by remissions and exacerbation. A mnemonic for the clinical features of multiple sclerosis is VISUAL: V: Visual disturbances such as blurring, double vision. I: Internuclear ophthalmoplegia (ie, of the brain stem pathway that coordinates eye movement), which causes paresis of the medial rectus muscle on lateral conjugate gaze, but not on convergence; nystagmus is seen in the abducting eye. S: Sensory sensations (tingling, pins and needles, numbness, dead-feeling limbs, band-like tightness). U: Unusual clumsiness, extremity weakness, leg dragging, muscle stiffness, limb heaviness. A: All symptoms provoked and/or intensified by hyperthermia. L: Lhermitte's sign. Flexion of the neck produces an electrical sensation that runs down the back and into the legs. This sign suggests intramedullary disease of the cervical cord.


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