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JAMA Ophthalmology Clinical Challenge
October 06, 2016

Decreased Vision and Cognitive Decline

Author Affiliations
  • 1Connecticut Uveitis Foundation, West Hartford
  • 2Eye Disease Consultants, Hartford, Connecticut
JAMA Ophthalmol. Published online October 6, 2016. doi:10.1001/jamaophthalmol.2016.2747

A man in his 40s was referred for a 1-year history of decreased vision and the sensation of tunnel vision, which accompanied cognitive decline for the past 2 years. He had a history of renal cell carcinoma and had undergone left nephrectomy 1 year prior with no recurrence. Prior to presentation, his evaluation included brain magnetic resonance imaging and neurologic evaluation with unremarkable results, and he was scheduled to undergo neuropsychological testing.

Visual acuity was counting fingers OD, and 20/100 OS. Motility and intraocular pressures were normal. There was a right afferent pupillary defect. Examination of the right eye revealed rubeosis iridis, a clear lens, neovascularization of the optic disc, retinal vasculitis, venous sheathing, and a dusky-appearing peripheral retina. The left eye had a clear lens and a normal fundus on clinical examination. Fluorescein angiography demonstrated a mixed retinal arteritis and phlebitis with extensive retinal and choroidal nonperfusion of the right eye with both retinal and optic nerve neovascularization. The left eye demonstrated patches of active arteritis peripherally with a minimally affected posterior pole (Figure).

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