Healio
Healio
March 20, 2017
2 min read
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PUBLICATION EXCLUSIVE: Woman presents with cloudy declining vision and flashes

A 56-year-old Caucasian woman presented with painless, slowly decreasing “murky” vision in the left eye over a period of 3 weeks, along with flashes. Her ocular history was positive for hemorrhagic posterior vitreous detachment after blunt trauma with a basketball to the same eye 4 months earlier. On that exam, she was also noted to have “fullness of the optic nerve, venous beading and inferior drusen OS.” Despite the physician’s recommendation to return after 4 to 6 weeks, the patient was lost to follow-up until new visual symptoms started. She had also undergone strabismus surgery 30 years earlier and had incipient cataracts, myopia and presbyopia.

Medical history included migraines and osteoarthritis. She was taking eletriptan, magnesium oxide and melatonin. Family history was only positive for coronary artery disease and diabetes in the father. She was working as a sales engineer and denied any history of intravenous drug use or high-risk sexual activity. Review of systems was positive for remote history of genital herpes.

Upon presentation, the patient was diagnosed with multifocal choroiditis with panuveitis and vasculitis and was referred to the Uveitis Service.

Figure 1. Wide-field scanning laser ophthalmoscopy photograph (Optos) showing numerous small hypopigmented lesions in the mid-periphery as well as pale subretinal plaques temporally and superonasally (a). ICGA highlighted the sharply delineated choroidal lesions in both the earliest frame (b) and after 16 minutes (c). The nummular retinal lesions appeared mostly hypoautofluorescent on FAF (d and e) and hyperfluorescent on FA at 1 minute (f) and 3:10 minutes (g). Not surprisingly, vitreous haze obscured the view of the posterior pole on multiple imaging modalities.

Images: Morkin MI, Rifkin LM, Shah CP

Examination

Best corrected visual acuity was 20/25 in the right eye and 20/100 in the left eye. The pupils were briskly reactive to light with no relative afferent pupillary defect in either eye, and IOP was 16 mm Hg in the right eye and 10 mm Hg in the left eye. Slit lamp examination of the right eye was unremarkable, while the left eye showed diffuse active keratic precipitates, trace anterior chamber cell, 2+ anterior vitreous cell, and 1 to 2+ vitreous haze. Fundus exam revealed left optic disc edema, numerous round mid-peripheral hypopigmented choroidal lesions along with focal subretinal plaques in the temporal, inferior and superonasal macula (Figure 1a). Indocyanine green angiography (ICGA) delineated the sharply defined choroidal lesions (Figures 1b and 1c) temporal to the macula in the left eye, while the right eye was unremarkable.

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