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JAMA Ophthalmology Clinical Challenge
September 2018

A Young Woman With Acute Visual Loss

Author Affiliations
  • 1Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
  • 2Siloam Eye Center, Seoul, South Korea
JAMA Ophthalmol. 2018;136(9):1066-1067. doi:10.1001/jamaophthalmol.2018.0063

A woman in her 20s presented with sudden-onset visual loss of the right eye for 1 day. Best-corrected visual acuity was 20/400 OD and 20/20 OS. She denied any eye pain with ocular movement or positive visual phenomena during presentation. She had recently traveled to Ireland, where she rode a horse. She denied previous upper respiratory and gastrointestinal tract infections. She had no other abnormal neurologic signs or symptoms. Results of slitlamp examination were normal. A relative afferent pupillary defect 1+ was noted in the right eye. Dilated fundus examination showed no evidence of vitritis, optic nerve swelling, or retinal pigment epithelial abnormalities. Automated visual field testing showed a central scotoma in the right eye, and the visual evoked potential showed a delayed P100 response in the right eye. Results of an initial ophthalmologic workup, including fundus photography and fluorescence angiography, were considered to be unremarkable. Contrast-enhanced magnetic resonance imaging of the brain and orbit revealed no enhancement of the optic nerves. At a subsequent visit, 2 small glistening lesions in the retina were identified, and optical coherence tomography (OCT) showed an attenuated ellipsoid zone at a position nasal to the fovea (Figure 1).