Differential Diagnosis for 13-year-old Girl with Intermittent Visual Disturbances

• Single most likely diagnosis:
  • Visual Migraine or Ocular Migraine: This condition is characterized by recurrent episodes of transient visual disturbances, such as blurred vision, blind spots, or seeing patterns, which can be triggered by various factors including stress, light, or hormonal changes. The improvement in dimmer environments and the absence of headache or other neurological symptoms support this diagnosis. The patient's age and the nature of the visual disturbances also align with this condition.
• Other Likely diagnoses:
  • Anxiety-related Visual Symptoms: Given the patient's heightened worry regarding her symptoms and the presence of anxiety in the family, it's possible that her visual disturbances are exacerbated or triggered by anxiety. The symptoms could be a manifestation of her psychological state rather than a purely neurological or ophthalmological issue.
  • Dry Eye Syndrome: This condition can cause visual disturbances, especially in environments with low humidity or after prolonged periods of focusing (e.g., in a classroom). The improvement in dimmer environments could be related to reduced tear evaporation.
  • Refractive Errors or Other Ocular Conditions: Although the optometry assessment was normal, it's possible that the patient has an undiagnosed refractive error or another ocular condition that is contributing to her symptoms, especially if the assessment did not include all necessary tests (e.g., detailed refraction under cycloplegia).
• Do Not Miss diagnoses:
  • Multiple Sclerosis (MS): Although less likely given the patient's age and the nature of her symptoms, MS can present with a wide range of neurological symptoms, including visual disturbances. The absence of other neurological symptoms and normal neuro exam make this less likely, but it's crucial to consider given the potential severity of MS.
  • Brain Tumors: Any new onset of neurological symptoms, including visual disturbances, warrants consideration of a brain tumor, especially if there are signs of increased intracranial pressure (e.g., papilledema), which is not present in this case.
  • Temporal Lobe Seizures: These can cause visual auras or disturbances. The patient's symptoms could potentially be a seizure manifestation, although the lack of other seizure-like activity or post-ictal phases makes this less likely.
• Rare diagnoses:
  • Mitochondrial Myopathies: Conditions like Kearns-Sayre Syndrome can cause chronic progressive external ophthalmoplegia and may have associated visual disturbances, though these are typically more constant rather than episodic.
  • Leber's Hereditary Optic Neuropathy (LHON): A rare inherited disorder that can cause sudden, irreversible vision loss, typically in young males, but could potentially present with preceding visual disturbances in some cases.