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JAMA Ophthalmology Clinical Challenge
May 2016

Bilateral Visual Disturbances in a Young Woman

Author Affiliations
  • 1The Retina Service of Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
  • 2Mid-Atlantic Retina, Philadelphia, Pennsylvania
JAMA Ophthalmol. 2016;134(5):593-594. doi:10.1001/jamaophthalmol.2015.3628

A woman in her 30s presented with 3 weeks of distorted vision in her right eye and a visual field defect in the left eye. This was her first episode, and she denied any pain. Visual acuity was 20/25 + 2 OD and 20/20 OS. Confrontation visual fields detected a superior field defect in the left eye. Pupils, intraocular pressures, and anterior segment examination results were within normal limits. Dilated fundus examination revealed whitening and attenuation of a small arteriole in the inferior arcade of the right eye (Figure, A). Examination of the left eye revealed an inferior branch retinal artery occlusion and a patch of retinal whitening superior to the optic disc approximately one-third disc diameter in size (Figure, B). No Hollenhorst plaques were identified. Fluorescein angiography demonstrated segments of arteriole hyperfluorescence with distal nonperfusion in both eyes (Figure, C). This hyperfluorescence and nonperfusion occurred within straight arteriole segments, not at arteriole bifurcations. The differential diagnosis included systemic lupus erythematosis, polyarteritis nodosa, Behçet disease, granulomatosis with polyangiitis (Wegener disease), acute retinal necrosis, syphilis, and hypercoagulability. An outpatient workup composed of fluorescent treponemal antibody absorption, QuantiFERON–TB Gold (Quest Diagnostics), erythrocyte sedimentation rate, antinuclear antibody, complete blood cell count, prothrombin time, and partial thromboplastin time was ordered.

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