History of Present Illness
A 68-year-old man presents with 2-week history of painless unilateral loss of vision in the left eye (OS). He noticed a paracentral scotoma OS, and while hunting with a shotgun just realized that he has no central vision right eye (OD). He denies photophobia, photopsia, or floaters in either eye .
| OD | OS | |
|---|---|---|
| Visual acuity | 5/400 | 20/40 |
| Intraocular pressure (IOP) (mm Hg) | 11 | 11 |
| 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. No cells | Trace cells |
| Retina/optic nerve | See Fig. 34.1 . Serpiginous chorioretinal scars originating from optic disc and extending to midperipheral retina. | See Fig. 34.2 . A chorioretinal scar within the macula and extending along the superotemporal (ST) arcade. Creamy subretinal lesions are noticed at the inner margin. |
Questions to Ask
- •
Has your vision been tested within the past few years?
- •
What is your general health? Have you been diagnosed with a systemic disease?
- •
Have you had ocular trauma to either eye that required surgery or visit to an emergency room?
- •
Have you traveled to an area of the country with a history of fungal disease?
His visual acuity (VA) was not tested within the past few years, and he did not notice any visual problem until recently. He denies a history of a systemic or autoimmune disease. There is no history of ocular trauma to either eye that required surgery or a visit to an emergency room. He has lived in the Ohio Valley most of his life and occasionally traveled to the Southwest United States.
Assessment
- •
Chorioretinitis, remote OD and acute OS, unknown etiology
Differential Diagnosis
- •
Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)
- •
Relentless placoid chorioretinitis
- •
Persistent placoid maculopathy
- •
Infectious retinitis (tuberculosis [TB], outer-layer retinal toxoplasmosis, syphilis)
- •
Presumed ocular histoplasmosis syndrome (POHS)
- •
Multifocal choroiditis (MFC)
- •
Sarcoid choroiditis
Working Diagnosis
- •
Serpiginous choroiditis, both eyes (OU)—remote OD, acute OS
- •
A bilateral asymmetric disease that affects healthy patients from the second to seventh decade and presents with unilateral loss of vision and characteristic peripapillary serpiginous chorioretinal lesions. Diagnosis is made by the typical clinical appearance and history.
- •
Testing
- •
Laboratory results: Venereal Disease Research Laboratory/rapid plasma reagin (VDRL/RPR), fluorescent treponemal antibody absorption (FTA-ABS), QuantiFERON–TB Gold In-Tube test (QFT-GIT), and chest x-ray are all normal.
- •
Fundus fluorescein angiography (FFA) ( Fig. 34.3 ) to identify the active edge of the acute lesion and to rule out choroidal neovascularization (CNV), which may develop adjacent to the active edge of the lesion.
