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JAMA Ophthalmology Clinical Challenge
February 2017

Unilateral Optic Nerve Edema With Preserved Visual Function

Author Affiliations
  • 1Department of Ophthalmology, University of Toronto, Toronto, Ontario, Canada
JAMA Ophthalmol. 2017;135(2):157-158. doi:10.1001/jamaophthalmol.2016.3787

A man in his 50s reported a 4-week history of intermittent blurry vision in the right eye. Review of systems was positive for a skin rash on the upper arms and trunk, which he noticed 2 months earlier. Medical history included well-controlled type 2 diabetes treated with metformin and sitagliptin.

Best-corrected visual acuity was 20/20 OU. There was a barely perceptible right relative afferent pupillary defect. Anterior segment examination was normal. On ophthalmoscopy, there were few vitreous cells with no detectable haze and optic nerve head edema grade IV on the Frisén scale, with peripapillary flame hemorrhages in the right eye (Figure); the optic nerve was normal on the left. Automated perimetry using the 24-2 pattern and Swedish interactive threshold algorithm strategy (Humphrey Field Analyzer; Carl Zeiss Meditec) was normal in each eye and optical coherence tomography showed marked elevation of the peripapillary retinal nerve fiber layer on the right. The remainder of the neurological examination was normal.