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—Dr Weintraub raised the question of vertebrobasilar insufficiency as a cause of the symptoms in the 63-year-old woman who complained of difficulty focusing her eyes in the morning and after looking down for a period of time. Her symptoms were better after her eyes were dilated for an ophthalmologic examination. Weintraub first seeks to explain the chronic tinnitus by anterior inferior cerebellar artery distribution ischemia (a rare cause of tinnitus). He then explains the accommodation problems as symptomatic of ischemia to the Edinger-Westphal nucleus; however, it is unlikely for a recurrent vascular event to be so extremely localized in nature. Even more unlikely is an explanation that cervical flexion associated with the patient looking down would give such a localized symptom as "difficulty focusing her eyes." To recommend a magnetic resonance angiogram in this woman for such an unlikely explanation of her symptoms is even more questionable, given
Mohr DN. Isolated Visual Symptoms in an Older Woman-Reply. JAMA. 1995;274(4):303. doi:10.1001/jama.1995.03530040029030