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JAMA Ophthalmology Clinical Challenge
December 6, 2018

New Onset of Blurred Vision and Floaters

Author Affiliations
  • 1Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland
  • 2Department of Ophthalmology, Baylor College of Medicine, Houston, Texas
JAMA Ophthalmol. Published online December 6, 2018. doi:10.1001/jamaophthalmol.2018.4511

A 38-year-old man with a history of refractive surgery in both eyes and well-controlled HIV receiving antiretroviral therapy (CD4+ lymphocyte count, 881) presented with worsening blurry vision and floaters in the left eye for 3 weeks in the setting of sinus congestion and left-sided jaw pain for 6 months. He denied flashing lights, visual field defects, trauma, pain, redness, discharge, or other systemic symptoms.

On examination, the patient’s uncorrected visual acuity was 20/20 OD and 20/50 OS (no improvement on refraction), his pupils were equally round and reactive with no relative afferent pupillary defect, his intraocular pressures were normal, and extraocular motility and confrontational visual fields were full. Results from slitlamp and dilated fundus examinations of the right eye were normal. Anterior segment examination of the left eye showed mild fine keratic precipitates and pigmented cell; dilated fundus examination showed significant vitritis but no obvious vascular sheathing or chorioretinal lesions (Figure 1A). Optical coherence tomography of the macula confirmed there was no intraretinal or subretinal fluid (Figure 1B), and fluorescein angiography did not show any vascular leakage or areas of nonperfusion. Results of further workup showed normal complete blood cell count and comprehensive metabolic panel laboratory testing, undetectable HIV viral load, and unremarkable chest radiography; laboratory results for tuberculosis (T-SPOT.TB testing), syphilis (rapid plasma reagin with reflex treponemal testing), cytoplasmic and perinuclear antineutrophil cytoplasmic antibodies, and blood cultures were all negative as well.

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