Differential Diagnosis for 71 yo F with Transient Vision Changes and Ear Pain

• Single most likely diagnosis:
  • Transient Ischemic Attacks (TIAs): The patient's history of hypertension, aortic valve replacement, and pulmonary hypertension increases her risk for cerebrovascular disease. The transient vision changes, described as blurring and graying out of parts of her vision without pain, could be indicative of TIAs, especially given their brief duration and lack of specific triggers. The occurrence of these episodes over several years with a relatively low frequency might suggest a vascular origin.
• Other Likely diagnoses:
  • Migraine with Aura: Although the patient questions whether she has migraines, her description of transient vision changes, including seeing a bright light in a straight line on some occasions, could be consistent with a migraine aura. The absence of headache does not rule out this diagnosis, as some individuals experience acephalgic migraines.
  • Ocular Migraine: Similar to migraine with aura, ocular migraines could explain the transient, episodic vision changes without headache. The visual symptoms described could fit this condition.
  • Dry Eye Syndrome: Given her history of varicose veins in both eyes and other ocular conditions, dry eye syndrome could contribute to transient vision changes, especially if these changes are related to environmental factors or occur at times when the eyes are more dry (e.g., upon waking).
• Do Not Miss diagnoses:
  • Giant Cell Arteritis (GCA): Although less likely given the patient's age and the nature of her vision changes, GCA is a critical diagnosis not to miss due to its potential for causing permanent vision loss. The new onset of ear pain could be related to GCA, especially if it involves the temporal region.
  • Retinal Detachment: Given her history of posterior vitreous detachment and floaters, any new or worsening vision changes should prompt an evaluation for retinal detachment, which is an emergency.
  • Stroke: While the patient's episodes seem transient and not clearly indicative of a stroke, any new neurological symptom, including vision changes and ear pain, should prompt consideration of a stroke, given her vascular risk factors.
• Rare diagnoses:
  • Occipital Lobe Seizures: These could present with transient visual disturbances, including blindness or altered vision, but are less common and would typically be associated with other seizure-like activity.
  • Vasculitis: Conditions like systemic lupus erythematosus or other vasculitides could potentially cause a wide range of symptoms, including vision changes and ear pain, but would be less likely without other systemic symptoms or findings.