History of present illness
A case of a 26-year-old female patient with new-onset flashes and floaters in his right eye more than his left eye is reported. He had had similar symptoms a year before presentation that rapidly (over the course of weeks) affected his right eye.
Ocular examination findings
Visual acuity was 20/25 in the right eye and 20/20 in the left eye. Anterior chambers were quiet bilaterally, and there was no evidence of vitritis. Initial examination revealed an afferent pupillary defect of the right eye. Visual field testing revealed an enlarged blind spot/temporal scotoma of the right eye ( Fig. 34.1 ).
Laboratory workup
Extensive laboratory workup to exclude systemic diseases, including infectious entities and masquerade syndromes, was performed.
- ■
Antinuclear antibody titer was positive at 1:40, and thyroid-stimulating hormone was low (0.03 mIU/L), indicative of Graves disease.
- ■
Antineutrophil cytoplasmic autoantibody screen, angiotensin-converting enzyme levels, lysozyme, Lyme disease antibody screen, rapid plasma reagin, fluorescent treponemal antibody absorption, interferon gamma release assay for latent tuberculosis, ssDNA autoantibodies, rheumatoid factor (immunoglobulin [Ig]A and IgG), cyclic citrullinated peptide, herpes simplex virus 1 and 2 IgG and IgM antibodies, interleukin-6 serum levels, urinalysis, and hepatitis C antibody were all within normal range.
Imaging
Brain magnetic resonance imaging at the onset of symptoms was unrevealing. Ophthalmoscopy revealed a zonal, well-demarcated yellowish area centered around the optic nerve, more prominent on confocal color imaging than on standard color fundus photography ( Figs. 34.2 and 34.3 ). Optical coherence tomography (OCT) demonstrated peripapillary outer retinal atrophy with thinning of the outer nuclear layer over disruption of the ellipsoid and interdigitation zones. The retinal pigment epithelium (RPE) was attenuated ( Fig. 34.4 ). OCT of the left eye appeared normal ( Fig. 34.5 ). Fundus autofluorescence (FAF) showed hypoautofluorescence within the affected region of the right eye with hyperautofluorescence at its margin ( Fig. 34.6 ).
