History of Present Illness
A 25-year-old woman developed a “flulike” illness 4 weeks ago. In the past 48 hours she suddenly developed painless loss of vision in the left eye (OS) without redness or photophobia. She noticed a small blind spot and shimmering lights (photopsias) in her temporal visual field. The night before her loss of vision, she attended a party and snorted cocaine for the first time.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/20 | 20/80 |
| Intraocular pressure (IOP) (mm Hg) | 11 | 10 |
| 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 | Clear | Trace vitreous cells |
| Retina/optic nerve | Normal | Small white dots, deep in retina ( Fig. 33.1A ), with hyperemia, trace optic disc edema, and foveal granularity ( Fig. 33.1B ) |
Questions to Ask
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Have you had sudden visual loss in either eye before now?
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Have you fully recovered from the flu—namely, do you still have malaise, lethargy, or tiredness?
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Have you been diagnosed with a blood or bone marrow disorder in the past?
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Are you being treated for any systemic disease affecting other organs?
Her answer to each question is “no,” except although she has recovered from the flu, she still has mild malaise.
Assessment
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White dot syndrome OS
Differential Diagnosis
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Multiple evanescent white dot syndrome (MEWDS)
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Punctate inner choroidopathy (PIC)
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Multifocal choroiditis (MFC)
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Lymphoma or other bone marrow disorder
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Sarcoidosis
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Infectious retinitis
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Central/branch retinal artery occlusion secondary to cocaine use
Working Diagnosis
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MEWDS with trace optic disc edema, OS
Testing
Diagnosis of the white dot syndromes is usually based on the classic fundus appearance. Thus although the differential diagnosis suggests other possible causes, laboratory testing is usually confined to ocular functional and imaging studies. Snorting of cocaine can cause unilateral central/branch retinal artery occlusion, which can result in severe visual loss, but the fundus appearance in this patient is not consistent with this diagnosis.
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Humphrey visual field (HVF): enlarged blind spot, OS; normal right eye (OD)
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Fluorescein angiography (FA): late retinal punctate staining, frequently in a wreathlike pattern, OS ( Fig. 33.2 )
