Optic Neuropathies

This 28-year-old otherwise-healthy woman was referred to for treatment of what was thought to be optic neuritis OD. Three weeks earlier she had noted a dark inferior scotoma OD that progressed to involve fixation over the next 10-12 days. She experienced photopsias OD at the onset. She had no viral prodrome. In retrospect, she recalled a vague, dull, nonspecific right-sided orbital and forehead ache (not made worse by eye movement) at the onset. When first seen by an ophthalmologist, 1 week after her symptoms began, pertinent findings included 20/40-2 acuity OD, symmetrical color vision using Ishihara plates, equivocal afferent pupillary defect, and slight hyperemia of the optic disc. She was diagnosed with optic neuritis and referred to a neurologist, who found no other neurologic abnormalities of concern and obtained an MRI that was normal. She declined intravenous pulse corticosteroid treatment and wanted another opinion because of confusion surrounding the issues of treatment. The only past history issue of importance was a bout of optic neuritis OS 9 years earlier, when she presented with painless central field photopsias and blur and was found to have 20/50 acuity, slight Marcus Gunn pupil, and no abnormalities of the posterior pole. She achieved excellent recovery after several weeks. When she was seen in initial neuro-ophthalmologic assessment, 3 weeks after the onset of the visual loss OD, her vision had already started to recover. Pertinent abnormalities of the examination included acuities of 20/25 OD and 20/20+1 OS, normal and symmetrical color vision using American Optical plates, a slight 0.3 (at most) log unit RAPD OD, a vague paracentral inferior scotoma connecting to the blind spot OD, and subtle areas of stippled macular depigmentation with a yellow-orange hue on the right and subtle granularity of the macula on the left. Pair with 96_13, 96_14, 96_15, 96_16, 96_17, 96_18, and 96_19.