Now You See It, Now You Don't: The Mystery Pupil
One Sunday afternoon, my 22-year-old daughter Teresa made an unscheduled trip to the E.R. with a very strange—and potentially dangerous—sign of brain injury.
Earlier that Sunday, Teresa had developed a headache and begun feeling lightheaded. Her left eye hurt. Something was wrong with the vision in that eye, too—everything looked “warped” or “wavy.” When she stepped into the bathroom to look in the mirror, what she saw scared her.
Her right eye looked normal. The iris of her left eye had all but disappeared.
Still, she was calm. What could possibly be that wrong? A dust speck had lodged under her disposable contact earlier in the day, and she’d probably just scratched her eye removing the contact in a hurry.
Just to be sure, Teresa logged on to her laptop and searched a few medical sites. As she searched, her headache grew worse, and she had trouble keeping her eye open. The information she found online told her something dangerous might be happening and that she should seek medical help—fast.
By the time Teresa’s dad and I arrived at the hospital, she had already experienced her first CT scan. She waved to us from a gurney in a darkened room. The digital readout above her head showed a blood pressure too high for someone Teresa’s age.
A neurologist assigned to Teresa’s care quickly appeared to tell us the CT scan would need to be repeated as an angiogram to rule out a brain aneurism.
“How certain are you that’s what’s wrong?” Teresa asked.
“Let’s just wait and see how the test comes out,” he said.
While Teresa was undergoing the second CT scan, the doctor met with us in the hallway to explain his concerns. “Dilation in one eye is a common symptom of a brain bleed,” he told us. “We have to rule that out.”
He also explained other possibilities, should the aneurism theory prove to be false. None of them sounded like good news: spinal meningitis, multiple sclerosis, stroke.
Back in the trauma room, we didn’t wait long for results. The scan had showed nothing. Next, doctors would continue their search for the elusive aneurism with an MRI. After would come a lumbar puncture, or spinal tap, to further rule out bleeding around the brain or meningitis.
Because Teresa was receiving care in a large urban teaching hospital, noise and chaos seemed constant—and police uniforms seemed almost as prevalent in the hallways as medical scrubs and stethoscopes. A patient rode by handcuffed to his gurney.
“They sure make this look more glamorous on TV, don’t they?” my husband said.
In the midst of the chaos, an assault victim was slipped into the MRI line ahead of Teresa—leading her doctor to decide to opt for the spinal tap first, rather than lose time. Had we realized how sick this would later make her, we might have argued against the change in plans.
As the technician performed the spinal tap, he carefully capped four containers of spinal fluid and stood them upright, side by side, in a device constructed for that purpose. Every one looked clear as water.
“That’s good,” the technician told Teresa. “We won’t know for sure until it’s back from the lab, but at first glance, it looks clear.”
While we awaited results, medical students and residents and nurses popped in—one by one or in small groups—just to take a look. Most hadn’t seen this symptom in a patient before. One nurse or technician surprised us by asking if he could have a word alone with our daughter. Through the partly opened door, we saw him kneeling in front of Teresa, who was now sitting in a wheelchair. We later learned he had asked her if he could pray with her—a kind gesture we’re sure he meant to be comforting—but which highlighted for us the supposed severity of Teresa’s case.
As each test was completed and the word came back—all clear—we began to relax a bit. Yet we grew more puzzled, too. What was happening? Why couldn’t they figure out what was wrong?
Teresa’s blood pressure was coming down slowly, and her dilated pupil did not seem quite as large. At 11:30 p.m., now with the beginning of what would become a debilitating headache from the spinal tap, Teresa was finally wheeled to another floor for her MRI.
Well past midnight, Teresa’s dad and I listened to the loud clanging and banging coming from the area where her MRI was underway. Having had no experience with this, we were surprised at both the noise and the length of time the process took. Time dragged by, and we craved rest as much as we craved answers.
Close to an hour later, Teresa emerged, her arm across her eyes to shield them from the harsh hospital lights. She was once again delivered to the E.R. and settled in an exam room. Now her headache was extreme.
The MRI results would probably not be back for a few hours, a technician told us. Teresa would soon be admitted to the neurology floor, and almost suddenly, doctors seemed a little less concerned, a bit less rushed. It was 3 a.m., and our daughter just wanted to sleep. It seemed like a good time for my husband and me to rush home for a quick shower and change of clothes, a bite to eat. We did not know what would await us in just a few hours.
But on our way back to the hospital after sun up, my cell phone rang. It was Teresa, just calling to “check in.” She sounded tired, but otherwise fine. “On the way,” I told her.
A neurologist we hadn’t seen before greeted us in Teresa’s hospital room. He was accompanied by a small group of residents. “The MRI is unremarkable,” he told both them and us.
I leaned forward to look closer at Teresa’s eye, and the doctor assured me it did, indeed, appear to now be normal. An ophthalmologist was on the way to perform an exam and give his own assessment.
“What caused this?” I asked.
“Well, it could be a number of things,” he said, as if that answered it. Then he turned and left, his entourage in quick pursuit.
On cue, the ophthalmologist appeared and began his evaluation. “She appears fine,” he said. “My guess would be she somehow introduced bacteria into her eye that caused extreme irritation, and now it’s resolved.”
Teresa, her dad, and I exchanged looks. Two CT scans, an MRI, a lumbar puncture, and who knows how many blood draws for an irritation? Really?
Our last visitor, just ahead of the nurse with discharge papers, was the neurologist from the day before—the one who had ordered all the tests. He looked sheepish, and I wanted to tell him that it was okay, that we wouldn’t have wanted him to handle it any other way. I knew we’d feel differently when we’d seen the bill, but for now, the relief was enormous. And had there been an aneurism after all, hesitation might have been tragic.
“My visit is unofficial,” he said, “because I am not on your daughter’s team now that she’s been admitted to the floor. But if I were to make a diagnosis, in light of the test results, I would say your daughter may have had a retinal migraine.”
Like any migraine, he explained, this type can be preceded by an aura—a type of sensory warning like flashing lights, changes in vision, or blind spots. Some people have experienced tingling in their limbs, and cases have been documented where a sufferer was briefly paralyzed on one side of the body. The doctor also explained that migraine auras are not always followed by the actual headache—and since we were fairly certain Teresa’s devastating headache of the night before had resulted from the combination of a spinal tap followed quickly by an MRI—this made sense.
“I do have one question,” I said. “What should she do if this happens again?”
The doctor rubbed his chin. “That’s a good question,” he said.
As we pulled away from the hospital parking lot with our healthy daughter in tow, it occurred to me to examine the discharge papers. With so many differences of opinion, what would the “official” diagnosis read?
I laughed as I read the obvious answer: anisocoria—unequal pupil size. Well, nobody would disagree with that.