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Grand RoundsMark Mugavin M.D., MPHUniversity of Louisville School of MedicineDepartment of Ophthalmology & Visual Sciences10/2/2015

111SubjectiveCC: Painless Central Vision Loss OS

HPI: 38 year old AAF with history of hypertension, obesity, prior pulmonary embolism presents to ED with CC of persistent, painless central vision loss in her left eye for the last four days. Patient noticed black dots in her field of vision in her left eye which became most obvious while watching TV. Also described dull, bi-lateral headaches surrounding her frontal sinuses and felt funny. No flashes of light, floaters, curtains. Right Eye unaffected.

SubjectiveMedical HX: Hypertension, Obesity, Prior pulmonary embolism

Surgical HX: Prior tubal ligationOcular HX: MyopiaMedications: Lisinopril 10 mg q Day, Atorvastatin 20 mg q dayReview of Systems: Positive for paresthesias in her left hand noticed approximately one to two episodes a week for the last 3 months, no dysarthria, no overt clumsiness

Exam OD OS

VA(cc, near): 20/20 20/25-2

Pupils: 4 2 4 3 +APD OS

IOP: 15 17

EOM

Ishihara Plates 16/16 12/16

0000000044Exam: Anterior Segment ODOSEyelids/Eyelashes wnl ouConjunctiva/Sclera clear ouCornea Racial Melanosis OUAnterior ChamberFormed FormedIrisDark. Round Dark. RoundLens Clear ClearVitreous Clear Clear

Posterior Segment

Differential DiagnosisOptic NeuritisNon-Arteritic Anterior Ischemic Optic Neuropathy

MRI Axial Cut T2 Flair Sequence

MRI T2 Flair

Radiology Report"5 mm focus of restricted diffusion with decreased T1 and increased T2 signal is seen in the right frontal lobe white matter. Could represent focus of demyelination. Other small bilateral punctate foci on Increased FLAIR and T2 signal are seen within the periventricular and juxtacortical white matterHospital Course

VEP Obtained by NeurologyIncreased latency of the P-100 waveforms for both eyes (OD 117 and OS 116)Slowing of electrical conduction suggestive of demyelinationAssessment and PlanRetrobulbar Optic Neuritis Neurology Consult initiated. Pt started on Solumedrol 1 gm IV for 5 days Lumbar Puncture to eval CSF Visual Evoked PotentialsVisual Field in 2 weeks 38 yr old Female presenting with: 4 day hx of painless, new onset central scotoma dyschromatopsia endorsing paresthesiasrelatively unremarkable fundusMRI suggestive of demyelinating plaques.

Hospital CoursePt received 5 days of IV SolumedrolDay 5 of hospitalization reported significant improvement in vision deficitObjectively improved to 16 of 16 Ishihara Plates OULumbar PunctureOligoclonal Bands NegativeAlbumin 9.2 low (13.9 to 24.6)IgG Synthesis low

SerologyANA negativeLyme negativeVRDL NegativeACE NegativeThyroid Peroxidase 312 (nml