History of Present Illness
A 21-year-old college student was studying for finals in May and noticed a sudden decrease in vision in both eyes (OU). He had never experienced visual problems before and recently finished studying for the Medical College Admission Test (MCAT), so he wondered whether his symptoms were the result of stress. He is athletic and on the college basketball team.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/80 | 20/100 |
| Intraocular pressure (IOP) (mm Hg) | 10 | 11 |
| Sclera/conjunctiva | Clear. No injection | Clear. No injection |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | No cell or flare | No cell or flare |
| Iris | Normal | Normal |
| Lens | Clear | Clear |
| Vitreous cavity | No vitreous cells | No vitreous cells |
| Retina/optic nerve | Multiple yellowish, flat, creamy-colored placoid lesions in the posterior pole ( Fig. 32.1 ). Normal optic nerve | Retinal lesions similar to those OD |
Questions to Ask
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Have you had pain, redness, or floaters in either eye?
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Have you had any illness within the past 6 to 8 weeks?
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Did you experience transient hearing loss at the time of the flu?
He denies a history of pain, redness, or floaters in either eye. However, about 4 weeks ago he had the flu but has improved considerably. He had meningismus (stiff neck), slight hearing impairment, and occasional headaches while ill. However, they have almost totally resolved.
Assessment
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White dot syndrome, with loss of central vision, OU
Differential Diagnosis
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Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)
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Serpiginous chorioretinitis
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Relentless placoid chorioretinitis
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Persistent placoid maculopathy
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Choroidal vasculitis (lupus, polyarteritis nodosa)
Working Diagnosis
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APMPPE, OU
Testing
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Diagnosis is made based on the appearance of the retinal lesions and course of the disease. Laboratory testing is only indicated when signs of central nervous system (CNS) involvement are present.
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Fluorescein angiography (FA): hyperfluorescence of placoid lesions in the early phase, with staining in the late phase ( Fig. 32.2 )
