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JAMA Ophthalmology Clinical Challenge
May 2018

A Woman With Confusion and Blurred Vision

Author Affiliations
  • 1Department of Ophthalmology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
JAMA Ophthalmol. 2018;136(5):585-586. doi:10.1001/jamaophthalmol.2017.4592

A woman in her early 60s presented with bilateral progressive painless blurring of vision for 1 week, associated with metamorphopsia. She was otherwise well and had no history of tuberculosis or underlying immunocompromise. Her best-corrected visual acuity was 20/80 OD and 20/60 OS. Ophthalmoscopy revealed bilateral swollen, hyperemic optic discs with multifocal yellowish choroidal lesions located at the midperiphery and posterior pole of the retina. The lesions varied in size, ranging from one-fourth to twice the diameter of the optic disc. Punctate areas of choroiditis were also seen along the temporal arcades (Figure 1A). Results of fundus fluorescein angiography showed bilateral early hypofluorescence, with late staining and leakage from the optic discs. Results of systemic examination were normal, except for coarse crepitations of the right lung. The erythrocyte sedimentation rate was elevated, at 80 mm/h, as was the C-reactive protein level, at 20.2 mg/L (to convert to nanomoles per liter, multiply by 9.524). Chest radiograph showed consolidation in the right lower zone (Figure 1B). However, results of tuberculin skin test, sputum for acid-fast bacilli, and sputum culture were negative. Three days after initial presentation, the patient developed acute binocular horizontal diplopia and disorientation.

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