Optic Neuropathies

A previously healthy 28-year-old woman (except for a history of optic neuritis OS 9 years previously with full recovery) was referred for management of 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, at the onset of the visual symptoms she recalled a vague, dull, nonspecific right-sided orbital and forehead ache (not made worse by eye movement). When first seen by an ophthalmologist, 1 week after her symptoms began, examination in the right eye showed visual acuity of 20/40-2, intact color vision, an equivocal relative 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 sought a second opinion by a neuro-ophthalmologist. Three weeks after the onset of the visual loss OD, her vision improved to 20/25 OD (20/20+1 OS), normal color vision, a 0.3 log unit RAPD OD, a vague paracentral inferior scotoma connecting to the blind spot OD (with normal visual field testing OS), and subtle areas of stippled macular depigmentation with a yellow-orange hue on the right and subtle granularity of the macula on the left.