Acute Macular Neuroretinopathy

A 44 year old woman reports visualizing five omnipresent irregularly shaped spots with each eye, with a triangular shape flashing like a strobe light inside each spot for 6 months, waning over time, following flu symptoms. Medical history reveals a long history of typical complex migraine headaches with aura with visual symptoms, and a TIA, 5 years prior to presentation. She sustained a small right cerebellar stroke thought to be related to chiropractic high velocity neck manipulation with resultant vertebral artery injury,1 year prior to presentation. Family history reveals deep venous thrombosis and hypercoagulable state. On Examination patient has visual acuity of 20/20 in each eye, normal color perception bilaterally and abnormal Amsler grid. Dilated ophthalmoscopy reveals healthy appearing optic disks, multiple paracentral petalloid lesions in the macula bilaterally, and scattered hypopigmented lesions in the nasal periphery of the right eye. Visual field testing with HVF 30-2 reveals small paracentral scotomata bilaterally. OCT scanning reveals multiple paracentral hyperreflective band-like lesions in the outer retina of each eye at the level of the outer plexiform layer and/or outer nuclear layer. There are multiple parafoveal petalloid hyporeflective areas in the enface infrared image bilaterally. ICG angiography reveals some focal hypofluorescent areas corresponding to the lesions seen in infrared imaging bilaterally. These lesions are pronounced during the early and arteriovenous phases with no areas of hyperfluorescence. MRA of head and neck reveals fibromuscular dysplasia and lab work high homocysteine levels.