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JAMA Ophthalmology Clinical Challenge
December 2015

Cotton-Wool Spots Associated With Mild Nonprogressive Visual Loss

Author Affiliations
  • 1Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Retina-Vitreous Associates Medical Group, Los Angeles, California
JAMA Ophthalmol. 2015;133(12):1471-1472. doi:10.1001/jamaophthalmol.2015.1967

A healthy white man in his late 70s was referred to the retina clinic for evaluation of nerve fiber layer infarcts (cotton-wool spots). He had been experiencing nonprogressive diminished vision in his left eye for 6 weeks. He denied any history of diabetes or past ocular problems and reported having mild hypertension for which he was taking lisinopril. Review of systems was positive for fatigue of his tongue while eating but he denied any jaw claudication, fevers, malaise, joint pain, or weight loss. His best-corrected visual acuity was 20/25 OD and 20/30 OS. Pupillary and anterior segment examination in both eyes were unremarkable with the exception of bilateral nuclear sclerotic cataracts. Dilated fundus examination of the right eye showed a nerve fiber layer infarct (NFLI) inferior to the optic nerve (Figure 1A). In the left eye, there were several scattered NFLIs in the peripapillary region (Figure 1B). Fluorescein angiography (FA) showed relatively normal flow without evidence of occlusion or vasculitis. An extensive inflammatory and infectious laboratory workup revealed a hemoglobin level of 12.6 g/dL and elevated erythrocyte sedimentation rate and C-reactive protein level of 54 mm/h and 6.16 mg/L, respectively (to convert hemoglobin to grams per liter, multiply by 10, and C-reactive protein to nanomoles per liter, multiply by 9.524). Antinuclear antibody testing was positive (1:80 with homogenous pattern). Further workup including human immunodeficiency virus testing was nonrevealing.

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