Doctor of optometry diagnoses unusual life-threatening problem

The day started like any other day. In fact, Casey Nichols didn’t recognize the freak accident when it happened. After work that day in January 2022, he went to a regular exercise class that focused on upper body strength. 

When he returned to his Minneapolis home, his partner noticed something was wrong: Nichols’ face was slightly droopy on his left side and his left pupil seemed smaller than his right one. His left eye was also red and itchy.

At age 35, Nichols is healthy and fit. He’s never broken a bone or had surgery. He had an optometrist and went to regular comprehensive eye exams, so he figured he would make an appointment in the morning to see Dr. Wallerich.

Dr. Wallerich quickly realized there was a serious problem and diagnosed Nichols with two eye issues: Horner’s syndrome and anisocoria. Horner’s syndrome is when the affected eye has a decreased pupil size and an upper eyelid droop known as ptosis. Anisocoria is when the pupils are different sizes.

“If you’re in bright light, your pupil should be no more than one millimeter different compared to the other eye, and if you turn off the light, they should dilate, or get larger, at about the same amount in each eye,” Dr. Wallerich explained. “We turned off the lights, and in the darkness there was a significant difference between his eyes. His left eye wasn’t reacting the same, so I knew immediately we had something more serious.”

A key part of Nichols’ diagnosis came from Dr. Wallerich knowing his patient. He kept up with his annual comprehensive eye exams, and Dr. Wallerich had seen him about eight months earlier. So, he knew Nichols’ eyes were healthy at the time and something had changed.

The fibers that control pupil dilation loop through the body in an “odd way,” Dr. Wallerich explained, going from the brain, down through the spinal column, over the lungs and then up through the external and internal carotid arteries before heading back up to the eye. Based on this, he knew any of those major areas could have a problem that was affecting Nichols’ left eye.

As Nichols remembers it, Dr. Wallerich began asking “very specific questions,” including: Did you lift anything heavy above your head in the last 24 hours? Yes. Do you have pain in your neck? Yes. Is part of your face a little bit droopy? Yes.

Dr. Wallerich narrowed down his suspicions, now believing that his patient had dissected one of his carotid arteries while lifting weights.

The neck has two internal carotid arteries—one on the left, one on the right—that supply blood to the brain. Carotid dissections are very rare and often caused by a neck injury. The dissection can cause blood to stop flowing or cause a blood clot, which can lead to a stroke.

Dr. Wallerich told Nichols: “I don’t want to alarm you, but you need to go to the ER right now.”

The twin cities of St. Paul and Minneapolis, Minnesota, were in the middle of a COVID-19 surge and emergency rooms were packed. Dr. Wallerich called the ER to let them know Nichols was on his way. He told an ER physician on the phone that his patient needed to be seen immediately for imaging.

“That was very jarring to hear when I thought he was probably just going to give me an eyedrop,” Nichols said. “At the time he did not mention to me what it could have been and how serious it was, so that helped me not freak out for sure. He just said, ‘you need to go now; if this is what I think it is it’s life-threatening.’”

“I might have died. I very much think that he saved my life.” Casey Nichols’

The left internal carotid artery dissection was confirmed at the hospital. Nichols was put on blood thinners and was told not to lift anything over 10 pounds for six months to reduce his risk of a stroke. A few months later, the droop in his face returned to normal. Six months later, the doctors determined he had made a full recovery and could stop taking blood thinners.

In hindsight, Nichols recognized he should not have waited almost 24 hours to see a doctor. If someone is seeing changes in their pupil size, Dr. Wallerich recommends seeking medical eye care or emergency care immediately.

“I very much feel like had I not gone to see Dr. Wallerich—or had I gone to that workout class [again the next day], or had I seen another doctor that wasn’t able to think through those questions in the way he did—so fast and so accurate and on the nose what this obscure neurological thing was—I might have died,” Nichols said. “I very much think that he saved my life."

Michael Wallerich, O.D., MBA

Michael Wallerich, O.D., MBA, graduated from State University of New York College of Optometry. Directly after his residency, Dr. Wallerich became a traveling optometrist within skilled nursing facilities, assisted living centers, rehabilitation clinics and regional hospitals throughout the state of Minnesota. His clinical specialties include: neuro-optometric evaluations; contact lens evaluations, including specialty lenses; pediatric eye care and myopia management; geriatric eye care and inpatient care within nursing facilities.

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