Jonathan Micieli, Adriana Krizova, Walter Montanera
Optic Neuropathy; Malignant Melanoma
A 52 -year-old healthy woman presented with a 1-week history of blurred vision and "soreness" in her left eye. Neuro-ophthalmic examination revealed a visual acuity of 20/20 OD, 20/40 OS, left RAPD and left superior arcuate defect on Humphrey visual field testing. Dilated fundus examination demonstrated a right "disc-at-risk" and moderate left optic disc edema. She reported having 2 cats at home with a recent scratch on her leg and also had symptoms suggestive of obstructive sleep apnea (OSA). A differential diagnosis of neuroretinitis, non-arteritic anterior ischemic optic neuropathy (NAION) and optic neuritis was considered, but infectious workup was negative and polysomnography was not diagnostic of OSA. She was treated empirically with ciprofloxacin for presumed cat-scratch neuroretinitis, but her left eye vision significantly worsened to no light perception (NLP) 2 weeks after the initial visit. There was now severe left optic disc edema, mild venous dilation and tortuosity and significant intraretinal fluid in the macula. MRI brain and orbits with contrast revealed longitudinally extensive thickening and enhancement of the left optic nerve with surrounding fat stranding and no signs of demyelination in the brain. This was thought to represent severe optic neuritis, but AQP4-IgG, MOG-IgG and vasculitis workup were negative and chest X-ray was normal. She was treated with intravenous methylprednisolone 1gram daily for 5 days followed by Prednisone 1mg/kg daily, but her vision remained NLP 1 week later. She was referred for plasmapheresis and after the first session, she had worsening left eye pain. Repeat examination demonstrated a visual acuity of NLP OS and worsening left optic disc edema, diffuse retinal edema and a cherry-red -spot, indicating the interval development of a central retinal artery occlusion (CRAO). Repeat MRI brain/orbits with contrast showed decreased enhancement within the left optic nerve. A diagnostic test was performed.
Relation is Part of
NANOS Annual Meeting 2021: Walsh Session II
Jonathan A. Micieli, MD
Adriana Krizova, Walter Montanera
Spencer S. Eccles Health Sciences Library, University of Utah