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JAMA Ophthalmology Clinical Challenge
January 7, 2021

Worsening Floaters in a 68-Year-Old White Woman

Author Affiliations
  • 1David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
  • 2Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, Los Angeles
  • 3Retina Division, Stein Eye Institute, University of California, Los Angeles, Los Angeles
  • 4Doheny Eye Institute, University of California, Los Angeles, Los Angeles
JAMA Ophthalmol. Published online January 7, 2021. doi:10.1001/jamaophthalmol.2020.4612

A 68-year-old white woman was referred for worsening floaters in both eyes starting 2 years before presentation. Her medical history included hypertension and right-sided trigeminal neuralgia. On examination, her visual acuity with habitual correction had decreased to 20/60 OD and 20/40 OS from 20/30 OU 2 years prior. A slitlamp examination revealed normal conjunctivae, nuclear sclerosis cataracts in both eyes, and deep and quiet anterior chambers. On a dilated fundus examination, there was 2+ vitreous cell and floaters in both eyes and a blonde fundus in both eyes. Optical coherence tomography imaging confirmed cystoid macular edema (CME) in both eyes; the right eye had cystoid spaces in the inner nuclear, outer plexiform, and outer nuclear layers, and the left eye had small cystoid spaces in the inner nuclear layer (Figure, A and B). Fluorescein angiography showed leakage of the optic nerve in the right eye, with petaloid leakage in the macular right eye worse than in the left eye. A uveitis workup had unremarkable or negative results for a basic metabolic panel, a complete blood cell count with a differential, Quantiferon gold test, Lyme antibody tests, an angiotensin-converting enzyme level, a serum erythrocyte sedimentation rate, and chest radiography. Additionally, 4 months prior, the patient developed trigeminal neuralgia, with a magnetic resonance image with contrast of the brain revealing an enhancing mass in the right middle cranial fossa, extending into the Meckel cave and abutting the right trigeminal nerve (Figure, C).

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