History of present illness
A 20-year-old female college senior student presented with a chief report of “Jello-like” circles in her vision for 6 months, which began during a semester abroad in Madrid, Spain.
Six months ago the patient awoke with blurry circles in her central vision in both eyes. A few days before this, she had a flu-like illness with mild fever and muscle aches, which resolved without treatment. The circles have persisted unchanged since they first appeared. She was otherwise healthy and was on oral contraceptive medication.
She was examined by an ophthalmologist and neurologist in Spain. The ocular examination was reported as normal with vision of 20/20 in each eye. An extensive workup was undertaken including complete blood cell count, sedimentation rate, C-reactive protein, sodium, potassium, chloride, magnesium, iron, calcium, phosphorous, glucose, urea, uric acid, blood urea nitrogen, bilirubin, alkaline phosphatase, cholesterol, triglycerides, high- and low-density lipoprotein, vitamin B 12 , folic acid, serum proteins, rheumatoid factor, antinuclear antibodies, fluorescent treponemal antibody absorption, HIV, toxoplasmosis titer, Epstein-Barr titer, vitamin D, thyroid-stimulating hormone, and cortisol levels. Imaging included magnetic resonance imaging (MRI) of head and brain and MRI angiography of head and brain.
All the laboratory tests were normal or negative, and the MRI showed “multiple pin-point hyper-intense images of the cerebral hemispheres compatible with ischemic lesions of microangiography as a first possibility or demyelinating or postvaccination or postinfectious disease.” The MRI angiogram was normal.
The patient was prescribed lamotrigine, a medication used to treat seizures and bipolar disorders, and a mineral supplement.
Ocular examination findings
Visual acuity without correction was 20/20 in each eye. Pupils were 4 mm and equally reactive. Motility was full, and fields were full to confrontation. External and anterior segment examinations were normal, and intraocular pressures were 16 mmHg. The dilated fundus examination showed mild macular abnormalities in each eye ( Figs. 55.1 and 55.2 ). The margins of the right optic nerve were slightly blurred compared with the left optic nerve. The remainder of the fundus examination was normal. The patient drew semicircular patterns of visual abnormalities on Amsler grid testing of each eye ( Figs. 55.3 and 55.4 ).
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