Migrainous Binocular Peripheral Oscillopsia: A typical Persistent Visual Aura Without Infarction

An 18 year old female with history of migraine without aura reported the abrupt onset of continuous, irregular, rapid (“shaking”) movements of objects perceived on the periphery of her visual fields over both eyes, when fixating on any given target. Symptoms were not suppressed by monocular eye closure. In some form, she experienced incomplete tunnel vision (“pseudo-tunnel”), since the periphery of her fields was not totally dark, lost coloration or was populated by phosphenes. She had some inconsistent lightheadedness but no vertigo, and reported a moderate continuous mid-facial headache. She denied symptoms referable to any other cranial nerve dysfunction. Her ophthalmologic and repeated neurological examinations were normal showing symmetric eye movements, normal saccades and smooth pursuit, no nystagmus and no ataxia. Her brain MRI and MRA of the extra and intracranial vessels were normal. Her EEG showed a normal background in the absence of a focal slowing, epileptic discharges or periodic complexes. Her visual evoked responses were symmetric with normal latencies. Her visual field testing revealed no deficits, yet, she had initially persistent peripheral movement illusion over both eyes. Her ocular symptoms lasted for several weeks progressively dissipating with the prophylactic administration of topiramate. I suggest that this patient’s binocular peripheral oscillopsia represented persistent cortical oscillopsia without nystagmus, as a very rare atypical variant of migraine persistent visual aura without infarction. Cortical oscillopsia without nystagmus constitutes a neuro-ophtalmological syndrome, recently validated in a patient with neuromyelitis optica (NMO) and visual pathways demyelinating lesions. In my belief, this patient’s symptoms probably emanated from sustained cortical occipital hyper-excitability and from reverberating spreading cortical depression (CSD).