Reversal of vision metamorphopsia (RVM) also known as ‘room tilt illusion’ and ‘upside-down vision’ is a rarely reported symptom characterised by 180 degree vertical inversion of vision due to a central nervous system insult. This visual disturbance has rarely been described in the literature and the pathophysiology remains unclear.

Metamorphopsia is a perceptual distortion of an objects size, shape, colour or inclination. In contemporaneous literature, the most common aetiology is posterior circulation ischaemia, but there are other case reports of this phenomena occurring in disorders such as tumours, trauma and multiple sclerosis predominantly in the vertebrobasilar region. In this particular case, we discuss a 77 year old man who presented with acute, transient RVM, vertigo, dysarthria and headache on a background of preceding viral illness, ataxia and vomiting.

A Full neurological exam was performed, with particular focus on gaze disorders, visual fields, visual guided hand movements and cognition. Detailed imaging and blood tests were performed and the presenting features, examination findings and investigations are reviewed in detail.

This is a case study and literature review of RVM, one of a few cases where this rare visual disturbance has been documented as a result of vertebrobasilar ischaemia.

Imaging revealed a complete basilar artery occlusion and multiple acute infarcts in relation to the posterior circulation, right posterolateral cerebellum, right inferior cerebellar vermis and right posterolateral medulla. There was a full resolution of the patient’s RVM after anticoagulation was commenced.

This case is useful as it examines a rare symptom that only a handful of authors have reported. There is still uncertainty about the pathophysiology of RVM and as such, this case may help define anatomical localization for the central integrator of visual extra-personal orientation. Our case supports the theory that this phenomenon can occur as a result of a posterior circulation lesion.