# Clinical Cases: Special Senses ## Case 1: Retinal Detachment ### Patient Presentation **Demographics:** 58-year-old male **Chief Complaint:** Sudden visual disturbance in right eye for 2 days **History of Present Illness:** A 58-year-old myopic man (wears -8.00 diopter glasses) presents with visual changes in his right eye that began 2 days ago. He first noticed new floaters "like a swarm of gnats" and flashing lights in his peripheral vision. Yesterday, he developed a "curtain" or "shadow" coming down from the top of his vision in the right eye. He has progressive loss of vision in the affected eye. He denies eye pain, redness, or trauma. He had cataract surgery on the right eye 6 months ago. **Physical Examination:** - Vital signs: Normal - Visual acuity: Right eye 20/200, Left eye 20/25 with correction - Pupillary examination: Right relative afferent pupillary defect (RAPD) - Intraocular pressure: Right 10 mmHg, Left 16 mmHg - Slit lamp examination: Anterior segment unremarkable; pseudophakia (intraocular lens) in right eye - Dilated fundoscopic examination: - Right eye: Elevated, corrugated retina in superior and temporal quadrants with multiple horseshoe tears; macula still attached; vitreous hemorrhage - Left eye: Peripheral lattice degeneration but flat retina **Workup:** - **B-scan ultrasonography:** Confirms rhegmatogenous retinal detachment in right eye with attached macula - **Optical coherence tomography (OCT):** Macula attached but subretinal fluid approaching fovea **Diagnosis:** Rhegmatogenous retinal detachment of the right eye (macula-on) **Treatment:** - Urgent ophthalmology/retina surgery consultation - Pars plana vitrectomy with membrane peeling, endolaser photocoagulation, and silicone oil tamponade performed within 24 hours - Positioning (face-down) post-operatively - Silicone oil removal at 3 months - Final visual acuity 20/40 in right eye - Prophylactic laser photocoagulation to lattice degeneration in left eye **Clinical Pearl:** Retinal detachment results from separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE). In rhegmatogenous detachment, liquefied vitreous passes through a retinal tear into the subretinal space. High myopia is a major risk factor due to globe elongation and vitreous degeneration. The photoreceptors receive oxygen and nutrients from the RPE; prolonged detachment causes photoreceptor death. Macula-on detachments are surgical emergencies because macular detachment dramatically worsens visual prognosis. The classic symptom progression is floaters and photopsias (from vitreous traction and tear formation) followed by a progressive visual field defect (the "curtain" of detached retina). --- ## Case 2: Benign Paroxysmal Positional Vertigo (BPPV) ### Patient Presentation **Demographics:** 55-year-old female **Chief Complaint:** Spinning dizziness when lying down or turning over in bed **History of Present Illness:** A 55-year-old woman presents with episodes of intense spinning sensation (vertigo) for 2 weeks. Episodes are triggered by specific movements, particularly when she lies down, gets out of bed, or turns over in bed. Each episode lasts about 30 seconds and is accompanied by nausea. She feels perfectly normal between episodes. She denies hearing loss, tinnitus, ear pain, or fullness. She reports no recent head trauma or ear infections. She has been avoiding lying flat due to symptom severity. **Physical Examination:** - Vital signs: Normal - General: Comfortable at rest in sitting position - HEENT: Ears normal; hearing grossly intact bilaterally - Neurological: - Mental status: Normal - Cranial nerves: Intact including facial strength and hearing - Cerebellar: Normal finger-to-nose, heel-to-shin; no dysmetria - Gait: Normal, no ataxia - **Dix-Hallpike maneuver:** Positive on RIGHT side - after latency of 2 seconds, torsional upbeating nystagmus develops lasting 25 seconds; patient reports vertigo; nystagmus fatigues with repeated testing - **Dix-Hallpike maneuver:** Negative on LEFT side **Workup:** - Clinical diagnosis based on classic Dix-Hallpike findings - No imaging required for classic presentation - Audiometry: Normal (not mandatory but performed to exclude other vestibular disorders) **Diagnosis:** Right posterior canal benign paroxysmal positional vertigo (BPPV) **Treatment:** - Epley repositioning maneuver (canalith repositioning procedure) performed in clinic for right posterior canal - Resolution of symptoms after single treatment - Epley maneuver repeated once for residual mild symptoms - Patient educated on Brandt-Daroff exercises for home use if symptoms recur - Vestibular suppressants (meclizine) prescribed for as-needed use only - Symptoms resolved completely at 4-week follow-up **Clinical Pearl:** BPPV is the most common cause of vertigo, resulting from displacement of otoconia (calcium carbonate crystals) from the utricle into the semicircular canals, most commonly the posterior canal. Head movements cause the crystals to shift, creating abnormal endolymph flow and cupular deflection, which the brain interprets as rotation. The Dix-Hallpike maneuver provokes the characteristic geotropic, torsional, upbeating nystagmus with latency and fatigue. The Epley maneuver repositions the crystals back to the utricle and has >80% efficacy with a single treatment. BPPV is distinguished from central vertigo by brief duration, positional triggers, characteristic nystagmus pattern, and absence of other neurological signs. --- ## Case 3: Meniere's Disease ### Patient Presentation **Demographics:** 42-year-old female **Chief Complaint:** Recurrent episodes of vertigo, hearing loss, and ringing in left ear **History of Present Illness:** A 42-year-old woman presents with a 2-year history of episodic attacks affecting her left ear. Attacks begin with a sensation of fullness and pressure in the left ear, followed by roaring tinnitus, decreased hearing, and severe vertigo with nausea and vomiting. Episodes last 2-4 hours before gradually subsiding. She has had approximately 10 such attacks. Between attacks, she has noticed progressive hearing loss in the left ear, particularly for low-frequency sounds. She reports that high-sodium meals may trigger attacks. **Physical Examination:** - Vital signs: Normal - Between attacks: - Otoscopic examination: Normal tympanic membranes bilaterally - Weber test: Lateralizes to right ear (away from affected ear, indicating sensorineural loss on left) - Rinne test: Positive bilaterally (air conduction > bone conduction) - Neurological: No nystagmus at rest; cranial nerves normal; cerebellar examination normal **Workup:** - **Audiometry:** Left ear low-frequency sensorineural hearing loss (characteristic upsloping pattern); normal hearing right ear - **Electrocochleography (ECochG):** Elevated SP/AP ratio on left (suggestive of endolymphatic hydrops) - **MRI brain with IAC protocol:** Normal; no vestibular schwannoma - **Vestibular function testing (VNG):** Reduced vestibular response on left during caloric testing **Diagnosis:** Definite Meniere's disease (left ear) **Treatment:** - Dietary modifications: Low-sodium diet (<2g/day); limit caffeine and alcohol - Diuretic therapy: Hydrochlorothiazide 25 mg daily - Betahistine 24 mg twice daily (vestibular modulator) - Vestibular suppressants (meclizine, ondansetron) for acute attacks - Hearing evaluation with consideration for hearing aid as hearing loss progresses - Discussion of intratympanic therapies (steroids, gentamicin) if medical management fails - Reduction in attack frequency with dietary and medical management **Clinical Pearl:** Meniere's disease results from endolymphatic hydrops - distension of the endolymphatic compartment of the inner ear, though the underlying cause remains unclear. The tetrad of symptoms (episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness) distinguishes Meniere's from other vestibular disorders. Hearing loss initially affects low frequencies (unlike presbycusis) and fluctuates but becomes progressive and permanent. Attacks typically last hours (distinguishing from BPPV's seconds and vestibular migraine's minutes to days). Salt restriction reduces endolymph volume and remains a cornerstone of treatment. --- ## Clinical Image ![BPPV Dix-Hallpike maneuver](case_01_image.jpg) **Image Description:** Illustration demonstrating the Dix-Hallpike test for BPPV, showing patient positioning with head turned 45 degrees and rapidly lowered to a head-hanging position, along with the anatomical representation of otolith debris in the posterior semicircular canal. **Attribution:** Image from Wikimedia Commons (https://commons.wikimedia.org/), Creative Commons Attribution-ShareAlike license.