Let It Snow
Welcome to Byline Builders, Modern Optometry’s newest column featuring case studies authored by externs from MyEyeDr practices across the nation, with the guidance and support of their primary preceptors.
Historically, grand rounds were a cornerstone of medical education, presented in person within the hallowed halls of an auditorium. Physicians and specialists gathered to discuss and dissect patient cases, learning through direct interaction and collective insights. Today, the tradition continues, albeit in a more modern format. We now share these invaluable learning experiences through PowerPoint presentations and journal publications such as this. Despite the evolution in delivery, the core objective remains unchanged. Grand rounds serve as a crucial platform for us to empathize with, understand, and ultimately improve our ability to help our patients. By learning from one another, we can continue to enhance our collective expertise, ensuring we provide the most effective care possible.
Sincerely,
Osama Said, OD | Director of Externships and Residencies, MyEyeDr
A 20-year-old white female presented for a routine eye examination with a chief complaint of seeing “static” in her vision. The disturbance was described as tiny dots that flashed on and off. She stated that the visual distortion varied but was constant and had been there for as long as she could remember.
Histories, Examination, and Diagnostic Imaging
The patient’s medical history was significant for migraines, and she was taking fluoxetine. She had no allergies or ocular history. Her review of systems was normal.
Her BCVA was 20/20 OD, 20/20 OS, and 20/20 OU. Her color vision, stereo, cover test, pupils, and extraocular motilities were all normal. Her IOP was 16 mm Hg OU, measured with the iCare Tonometer (iCare).
Anterior segment examination showed a clear cornea, white and quiet conjunctiva, normal lids and lashes, clear lens, deep and quiet anterior chamber, normal iris without rubeosis, and 4+ angles.
Posterior segment examination showed a normal macula without hemes, edema, or drusen (Figures 1 and 2). The patient’s discs were flat and normal, and her vessels were normal without neovascularization. The periphery had a normal appearance without retinal tears, breaks, or holes. Additionally, the vitreous was clear without hemorrhages, cells, or pigment.
Anterior segment photos, fundus photos, OCT images, and visual fields were all normal.
DIAGNOSIS, MANAGEMENT, AND FOLLOW-UP
Based on the clinical findings and exclusion of other conditions including ocular migraine and subjective visual disturbance, the patient was diagnosed with visual snow syndrome (VSS). VSS is a challenging condition due to its unknown etiology and lack of ocular signs despite significant symptoms (see Criteria for VSS).1 There is currently no standardized treatment proposed for VSS. Migraine treatments are often unhelpful and may even worsen symptoms.1 There have been several trials evaluating potential VSS treatments with varying results.2 Several medications, including lamotrigine, sertraline, nortriptyline, and carbamazepine, have offered some improvement in VSS symptoms in individual cases but have not been consistently effective.1
Criteria for VSS1
To make a diagnosis of visual snow syndrome (VSS), a patient’s complaints/symptoms/signs must align with the criteria below, and not be consistent with those of a migraine, or be better explained by another disorder.
- Dynamic, continuous tiny dots in the entire visual field lasting longer than 3 months. (The dots are usually black/gray on a white background or gray/white on a black background; however, they can also be transparent, flashing, or colored.)
- Presence of at least two additional visual symptoms, including the following:
Palinopsia. Afterimages or trailing of moving objects. Afterimages should be different from retinal afterimages, which occur when staring at a high-contrast image and are in complementary color.
Enhanced Entoptic Phenomena. Excessive floaters in both eyes, excessive blue field entoptic phenomenon, self-light of the eye, or spontaneous photopsia.
Photophobia. Increased sensitivity to light.
Nyctalopia. Difficulty seeing in low light or at night.
- Symptoms are not consistent with typical migraine visual aura.
- Symptoms are not better explained by another disorder.
- Ophthalmology tests (eg, BCVA, dilated fundus examination, visual field, and electroretinogram) are normal.
The patient was advised to monitor her condition yearly. Her prognosis is good, with management focusing on associated symptoms, such as sensitivity to light, difficulty seeing at night, and tinnitus.
VSS IN THE LITERATURE
Studies have indicated hyperactivity in the visual cortex as a possible cause of VSS and suggest the disease affects less than 1% of the population and presents a clinical continuum with varying degrees of severity.3
A study of 1,100 cases investigating the current criteria of VSS and aiming to describe its phenotype found that common symptoms include black and white static, floaters, afterimages, photophobia, tinnitus, and migraines.4 The researchers confirmed the validity of previous cohort studies, indicating a clinical continuum with degrees of severity of VSS.
Further research is necessary to elucidate the etiology of VSS and develop effective management strategies to improve patient quality of life.
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