Reversal of Vision Metamorphopsia

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Background

Reversal of vision metamorphopsia (RVM) is a perceived 180-degree rotation of the visual field. The most common cause is vertebrobasilar stroke however there have been reported cases of RVM due to CNS tumors, multiple sclerosis, vestibular disorders, seizures, or brain trauma. Reversal of the visual field is usually transient and resolves without intervention.

History

The condition was first recognized in 1868 and was described at that time as “transient hysteria”. This term is no longer accepted and is considered pejorative. The term “reversal of vision metamorphopsia” was introduced in 1998 by Yaren River et al[1]. The condition is so rare that only 52 cases were reported from 1974 to 2022[2].

Epidemiology

There have been very few cases of RVM reported in the last 50 years and it is therefore difficult to determine accurate incidence and prevalence. However, a meta-analysis of all 52 cases reported in the last 48 years identified that most cases were in men (66%) and the mean age of onset was approximately 52 years. The average duration of RVM in those cases (with removal of outliers) was approximately 12 minutes.

Pathophysiology

A meta-analysis by Joshua Yap evaluated the etiology of the condition in all reported cases (52) of RVM in the last 48 years[2]. This review identified that RVM is most commonly due to acute infarct (34.6%) of the brainstem or cerebellum. The next most common cause was interruption of the peripheral vestibular pathway (21.2%) including CN VIII, the semicircular canals, and the otolith organs. The remaining cases had various etiologies including multiple sclerosis, transient ischemic attack, migraine, and seizure while the etiology remained unclear in some cases. Although the pathophysiology of RVM is not well understood, Yap proposes that there is a “multifocal, multinucleated visuospatial system” which processes the verticality of one’s environment and infarction or disruption of any part of this system may result in RVM. However, he suggests that as the remaining parts of the visuospatial system begin to compensate, the RVM resolves explaining the transient nature of the condition.

Summary

RVM is a very rare and unusual phenomenon that can be a presenting sign of a serious underlying condition. Patients that describe this phenomenon should promptly be evaluated at a stroke center with MR imaging of the head and neck as basilar artery strokes are an acutely life-threatening cause of RVM with a mortality rate of 85%[3].

  1. River Y, Ben Hur T, Steiner I. Reversal of Vision Metamorphopsia: Clinical and Anatomical Characteristics. Arch Neurol. 1998;55(10):1362–1368. doi:10.1001/archneur.55.10.1362
  2. 2.0 2.1 Yap J. Upside-down vision: A systematic review of the literature. BMJ Neurology Open. 2022;4(2). https://www.proquest.com/scholarly-journals/upside-down-vision-systematic-review-literature/docview/2712734581/se-2. doi: https://doi.org/10.1136/bmjno-2022-000337
  3. Lindsberg P, Soinne L, Tatlisumak T, et al. Long-term Outcome After Intravenous Thrombolysis of Basilar Artery Occlusion. JAMA. 2004;292(15):1862–1866. doi:10.1001/jama.292.15.1862
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