Occipital Lobe Epilepsy Masquerading as Episodic Visual Symptoms in a Young Professional

Case Report Occipital Lobe Epilepsy Masquerading as Episodic Visual Symptoms in a Young Professional Dr Sudhir Kumar MD (Medicine), DM (Neurology) Adjunct Professor & HOD, Neurology Dept, Apollo Hospitals, Hyderabad, India- 500096 Email: drsudhirkumar@yahoo.com Occipital Lobe Epilepsy Masquerading as Episodic Visual Symptoms in a Young Professional Introduction Occipital lobe epilepsy (OLE) is a relatively rare form of focal epilepsy, often presenting with paroxysmal visual symptoms that can mimic primary ophthalmic disorders or migraines. Because the initial semiology may be deceptively mild, such as brief blurring of vision, patients are frequently misdiagnosed or dismissed as having "stress-related" symptoms. We report a case of structural OLE in a 30-year-old woman where the progression to a generalized seizure led to the diagnosis of underlying occipital gliosis. Case Report History A 30-year-old female schoolteacher presented with a six-month history of episodic, brief blurring of vision. These episodes lasted for 3 to 5 minutes and occurred one to two times per month. She had previously sought consultation with two separate ophthalmologists, both of whom found her visual acuity and ocular examination to be unremarkable. Due to her professional demands, the symptoms were initially attributed to work-related fatigue, prolonged standing, and irregular meal patterns. One evening, following a typical episode of visual blurring, the patient experienced a loss of consciousness followed by a generalized tonic-clonic seizure (GTCS) and involuntary micturition. She regained consciousness spontaneously and was brought for neurological evaluation the following morning. Examination Upon presentation at the outpatient department (OPD), the patient was hemodynamically stable and neurologically intact. Bedside visual field testing and funduscopic examination were normal. There were no focal motor or sensory deficits noted. Investigations Given the focal onset (visual aura) progressing to a generalized event, an MRI of the brain was performed. The imaging revealed a focal area of high signal intensity on T2/FLAIR sequences in the right occipital lobe, consistent with gliosis. Diagnosis The clinical semiology (visual aura followed by secondary generalization) combined with imaging findings confirmed a diagnosis of Structural Occipital Lobe Epilepsy secondary to right occipital gliosis. Treatment The patient was commenced on appropriate anti-seizure medication (ASM) monotherapy (oxcarbazepine 150 mg twice daily), titrated to an effective maintenance dose (300 mg twice daily). She was educated on the nature of focal seizures and the importance of medication adherence. Follow-up At a three-month follow-up, the patient reported being completely seizure-free. The episodic visual blurring had ceased entirely. She has successfully returned to her teaching profession and resumed her normal daily activities with full confidence. Discussion Occipital seizures are characterized by visual phenomena, which may be "positive" (flashes, colors) or "negative" (scotomas, blurring). In this case, the patient's "blurring" was a focal awareness seizure. The diagnostic delay was exacerbated by the common tendency to rationalize mild neurological symptoms as manifestations of stress or fatigue. The progression to a generalized seizure, including autonomic involvement (involuntary urination), is a common trajectory for focal lesional epilepsy. This case highlights that any paroxysmal, stereotypical visual symptom, even if mild, should prompt a neurological evaluation to rule out a cortical focus, especially when ophthalmic examinations are normal. Summary This case underscores the importance of a meticulous clinical history in the evaluation of paroxysmal visual symptoms. What appeared to be simple work-related fatigue was, in fact, a treatable neurological condition. Early recognition of the "occipital aura" can prevent the progression to generalized seizures and significantly improve a patient's quality of life. References Panayiotopoulos CP. Visual phenomena and occipital seizures. Epilepsia. 1999;40 Suppl 4:3-10. Adcock JE, Panayiotopoulos CP. Occipital lobe seizures and epilepsies. Journal of Clinical Neurophysiology. 2012;29(5):397-407. Taylor I, et al. Visual symptomatology in occipital lobe epilepsy. Neurology. 2003;60(11):1805-1811.