History of present illness
A 65-year-old White man presented in 2015 with bilateral light sensitivity and 4 months of mobile, white spots in his vision that persisted when his eyes were closed. He also reported difficulty reading, as well as symptoms suggesting peripheral visual field constriction, such as difficulties with navigating.
Questions to ask
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Additional ocular symptoms
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No additional visual symptoms
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Medical history
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Testicular cancer (seminoma) in 1982, treated with chemotherapy and pelvic radiation. In 2013, he was found to recurrent seminoma. He had since been on surveillance with testing every 6 months (computed tomography scans, colonoscopies, and repeat routine blood work) revealing no evidence of metastasis or other cancers.
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Family history
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Strong family history of cancer: renal cell cancer (father), breast cancer (mother), colon cancer (brother)
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History of photopsias: autoimmune retinopathy patients describe shimmering or twinkling lights.
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This patient described moving white spots.
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Impaired dark adaptation due to progressive damage to rods when suspicious of autoimmune retinopathies
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This patient did not describe classic nyctalopia but did report constriction of visual fields, which could imply rod dysfunction.
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Social history: assess for possible social and travel risk factors for infectious causes, such as syphilis, human immunodeficiency virus, and tuberculosis.
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Negative
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Medications: assess for medications known to cause pigmentary retinopathy, such as phenothiazine, antipsychotics, chlorpromazine, and thioridazine.
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Noncontributory
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Review of symptoms: to assess for symptoms associated with causes of uveitis, white dot syndromes, infectious signs, and undiagnosed malignancy.
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No additional systemic symptoms in this patient
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Ocular examination findings
Visual acuity was 20/20 in the right eye and 20/15 in the left eye. Intraocular pressures were normal. Anterior segment examination was unremarkable bilaterally. Fundus examination demonstrated optic nerve pallor and attenuated arterioles with retinal pigmentary changes in both eyes ( Figs. 27.1 and 27.2 ).
Goldmann visual field testing demonstrated bilateral superior arcuate visual field defects, respecting the horizontal meridian.
Optical coherence tomography (OCT) demonstrated sparring of the outer retina at the fovea in both eyes with outer retinal loss involving the photoreceptors, ellipsoid zone, and external limiting membrane parafoveally in both eyes ( Figs. 27.3 and 27.4 ).
