What could be causing my episodes of cloudy vision, feeling like everything is far away or elongated, and my eyes rolling back in my head?

Urgent Neurological and Ophthalmological Evaluation Required

Your symptoms of eyes rolling back, cloudy vision, and distorted perception (objects appearing far away or elongated) require immediate medical evaluation to rule out serious neurological conditions, particularly increased intracranial pressure, seizure activity, or cranial nerve pathology.

Critical Red Flags Requiring Emergency Assessment

Your symptom constellation suggests potential involvement of multiple systems that demand urgent investigation:

• Eyes rolling back may indicate oculogyric crisis (involuntary upward eye deviation), sixth nerve palsy with gaze deviation, or seizure activity 1
• Cloudy vision with perceptual distortions (objects appearing distant or elongated) suggests possible visual processing dysfunction, which can occur with increased intracranial pressure, posterior circulation pathology, or ocular-motor system dysfunction 1
• The combination of these symptoms warrants immediate neuroimaging to exclude mass lesions, increased intracranial pressure, vascular abnormalities, or demyelinating disease 1

Immediate Diagnostic Workup

Essential Clinical Examination

You need a comprehensive evaluation focusing on:

• Pupillary examination in bright and dim lighting to assess reactivity, size, and shape—any asymmetry or poor reactivity suggests serious pathology 2
• Fundoscopic examination to identify papilledema (indicating elevated intracranial pressure) or optic atrophy 1
• Complete ocular motility testing including assessment for sixth nerve palsy (inability to move eyes outward), third nerve involvement, or other cranial neuropathies 1
• Visual acuity and visual field testing to detect any deficits 1
• Neurological examination for signs of motor weakness, sensory changes, or other cranial nerve deficits 1

Urgent Neuroimaging

Neuroimaging should be obtained immediately given your symptom pattern 1:

• MRI brain with and without contrast is the preferred study for evaluating structural lesions, demyelination, neoplasm, or vascular abnormalities 1, 2
• If MRI is unavailable or contraindicated, CT head without contrast should be performed emergently 2
• MRA or CTA may be needed if vascular pathology (aneurysm, arteriovenous malformation) is suspected 2

Additional Testing Based on Initial Findings

• Lumbar puncture following neuroimaging if there are signs of increased intracranial pressure (papilledema, bilateral sixth nerve palsy) or meningeal signs to measure opening pressure and evaluate for infectious, inflammatory, or carcinomatous meningitis 1
• Serologic testing including Lyme disease and syphilis if neuroimaging is unrevealing 1
• Blood pressure, glucose, and hemoglobin A1c to assess for vasculopathic risk factors 1
• ESR and C-reactive protein if there is any concern for giant cell arteritis (particularly if you have scalp tenderness or jaw pain) 1

Differential Diagnosis Framework

Primary Neurological Causes

Increased intracranial pressure from mass lesion, hydrocephalus, or idiopathic intracranial hypertension can cause:

• Sixth nerve palsy (eyes unable to move outward, causing inward deviation) 1
• Papilledema with visual disturbances 1
• The sixth nerve is particularly susceptible to stretching from elevated pressure due to its long intracranial course 1

Cranial nerve palsies affecting eye movement:

• Sixth nerve palsy causes esotropia (inward eye deviation) worse at distance, with inability to abduct the affected eye 1
• Third nerve palsy can cause eye deviation and if pupil-involving, suggests aneurysmal compression requiring emergency vascular imaging 2
• Cavernous sinus pathology can affect multiple cranial nerves simultaneously 1

Seizure activity can manifest with:

• Eye deviation or rolling back during ictal events
• Visual distortions or perceptual changes
• Altered consciousness or awareness

Ocular-Motor and Visual System Dysfunction

Ocular-motor subtype dysfunction following head trauma or concussion includes 1:

• Difficulty with visual focus and accommodation
• Blurred or double vision
• Problems with convergence and eye teaming
• Visual-derived symptoms including frontal headaches and difficulty with visual tasks
• Photophobia and difficulty tolerating complex visual environments

Divergence insufficiency or sagging eye syndrome (though typically presents differently) 1:

• More common in older adults (median age 74 years for divergence insufficiency) 1
• Causes esotropia worse at distance with diplopia
• However, your description of "eyes rolling back" is not typical for these conditions

Medication-Induced Causes

Oculogyric crisis from dopamine antagonist medications 3:

• Involuntary upward deviation of eyes
• Typically occurs with antipsychotic medications (particularly risperidone, paliperidone)
• Appears after first few doses or dosage increases
• Requires immediate recognition and treatment

Critical Pitfalls to Avoid

• Never delay neuroimaging when there are signs of cranial nerve involvement, altered eye movements, or visual distortions—these may indicate life-threatening pathology 1, 2
• Do not assume benign causes without excluding increased intracranial pressure, mass lesions, or vascular abnormalities first 1
• Any pupillary involvement requires full neuroimaging workup—never assume pupil-sparing presentation without careful examination 2
• Bilateral sixth nerve palsy is particularly concerning for increased intracranial pressure and requires urgent evaluation 1

When to Seek Emergency Care

Go to the emergency department immediately if you experience:

• Sudden onset or worsening of symptoms
• Severe headache, especially if different from usual headaches
• Fever, neck stiffness, or altered mental status
• New weakness, numbness, or difficulty speaking
• Persistent visual changes or loss of vision
• Any signs of decreased consciousness

Your symptoms are not typical of common, benign conditions and require prompt evaluation by a neurologist or neuro-ophthalmologist to determine the underlying cause and initiate appropriate treatment 1.