A twenty-two-year-old woman was brought to the emergency department by her mother for “uncontrollable eye movements.” The patient said, “Every time I close my eyes, my eyes will roll back in my head and I can’t stop them from moving.” She also had uncontrollable twitching all over her body. This had been going on for three weeks and was getting worse, causing trouble sleeping.
She had been to see her primary care doctor who prescribed something for sleep and referred her to a neurologist. Since she seemed to be getting worse, her mother didn’t want to wait for the neurology appointment and brought her to see me.
I watched the patient closely while asking detailed questions about her symptoms and medical history. All the while, I was forming and refining mental lists and questions for myself. After practicing emergency medicine for over thirty years, most of this takes place quickly and subconsciously, but it looks like this…
- What might cause something like this? Stroke, seizure, trauma, toxicity to medications or environmental substances, neurological conditions like multiple sclerosis, etc.
- Of the items on that list, what might happen to a twenty-two-year-old, healthy woman? What might come on rather slowly and get worse over three weeks?
- What might cause these symptoms and only these symptoms so there is no fever, headache, problems with equilibrium or vision, etc?
- Knowing what I know about the nervous system, the muscles that move the eyes and human behavior, can I find something on the list that might be a realistic consideration in the case of this patient?
- Is there some sort of laboratory test or imaging study that might help refine the list further?
The patient told me nothing that would help me understand what was going on. She had no past medical history. No psychiatric history. No drug or alcohol use. No exposure to toxins. No seizures or loss of consciousness. Nothing else. She already had blood testing and a CT scan of her brain that were normal.
While we were talking, the young woman sat on the side of the gurney. Everything about her presentation seemed normal: her mental status, hearing and speech. She showed none of the twitching her mother had described. She seemed completely comfortable with her eyes hidden behind dark sunglasses.
When I asked her to remove the glasses, her eyes rolled up so far only the whites, or sclerae, showed. Her eyes moved back and forth up under her half-closed lids.
After a minute or so of this eye rolling, she closed her eyes. I could see they quit moving from side to side and returned to a normal position behind her closed lids. After a few seconds of rest, she would again open her eyes, roll them up, and move them back and forth under her lids. This continued for as long as I was examining her face. As soon as she was allowed to do so, she put back on her sunglasses, which hid her eyes from view.
I asked the patient to perform a couple of simple tasks that test brain or neurological function, things like walking a straight line and moving her pointing finger back and forth between her nose and my finger. When doing these tests, the patient’s eyes came out from under her eyelids and she performed the tasks perfectly. Then, when the test was finished, her eyes rolled back up again.
By the time I was through examining this young woman, I was sure she was fine. I had no idea why she was moving here eyes in this strange way and there was no way to know for sure. Maybe she had some psychological issue that was stressing her out and causing symptoms that had no underlying physical disorder. Maybe she liked the attention and just loved having a concerned mother take her places where everyone paid close attention to her. I don’t know.
Before discharging the patient with reassurance and something stronger to help her sleep, I stopped and ask myself, one last time, if I might be fooling myself and missing something. This last consideration has helped me many times over the years as I try to do a very difficult job.
In the end, the patient put back on her sunglasses, the mother had all of her questions answered, they were assured that the patient would be fine until she could get to see the neurologist, and off they went with me wondering how it was all going to end up.