History of Present Illness (HPI)
A 36-year-old woman with no past ocular history and no significant past medical history complains of increasingly blurry vision in the right eye (OD). It started 2 weeks ago with some mild blurriness that has progressed to the point of a fuzzy gray spot in the center of her vision. The left eye (OS) seems the same as usual. In the last few days she has noticed some new floaters in the right eye as well ( Fig. 55.1 ).
| OD | OS | |
|---|---|---|
| Vision | 20/40− | 20/20 |
| Intraocular pressure (IOP) | 16 | 15 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | Clear | Clear |
| Anterior chamber (AC): | Deep and quiet | Deep and quiet |
| Iris: | Flat | Flat |
| Lens: | Clear | Clear |
| Anterior vitreous: | 1+ white cells | Clear |
Questions to Ask
- •
Do you have any pets or have you had interactions with animals in the past few months?
- •
Have you had unprotected sex?
- •
Any recent injuries or scratches?
- •
Have you traveled outside the United States recently?
She responds that she lives with two cats, but does not recall any recent trauma. She denies unprotected sex or traveling outside the country.
Assessment
- •
Neuroretinitis with mild vitritis OD
Differential Diagnosis
- •
Syphilis
- •
Bartonella
- •
Lyme disease
- •
Sarcoidosis
- •
Leber stellate neuroretinitis
- •
Systemic hypertension
- •
Less likely: toxoplasmosis, leptospirosis, tuberculosis, anterior ischemic optic neuropathy, Rocky Mountain spotted fever
Working Diagnosis
- •
Infectious neuroretinitis OD, unclear organism
Testing
- •
Rapid plasma reagin (RPR), fluorescent treponemal antibody absorption (FTA-ABS).
- •
Purified protein derivative (PPD) or QuantiFERON.
- •
Bartonella serologies.
- •
Lyme serologies with reflex Western blot.
- •
Check systemic blood pressure. It was checked in the clinic and was 112/75.
- •
Check optical coherence tomography (OCT, Fig. 55.2 ).
