Bilateral Severe Decreased Vision With Normal Examination Findings

Abstract

An adult patient with a medical history of systemic lupus erythematosus and cystic fibrosis was seen with painless, rapidly declining vision in both eyes of 1-month duration. The patient had initially seen a general ophthalmologist 1 week after noticing a change in vision and was diagnosed as having bilateral cataracts. Given a continued decline in vision over the next 2 weeks, the patient sought a second opinion. The patient reported taking 400 mg of hydroxychloroquine sulfate daily (6.3 mg/kg/d) during the past 2 years, with normal renal function, but denied any recent change in medications.On initial examination, visual acuity (VA) was counting fingers at 2 ft OD and at 3 ft OS. Intraocular pressures were 14 mm Hg OD and 16 mm Hg OS. Pupils were equal and mildly sluggish to react to light but demonstrated no relative afferent pupillary defect. Slitlamp examination revealed 1+ nuclear sclerosis cataracts. Dilated fundus examination demonstrated normal-appearing retinal and optic nerve architecture with the exception of mild arteriolar narrowing bilaterally (Figure 1A). Results of optical coherence tomography (OCT) of the retinal nerve fiber layer and macula, as well as fundus autofluorescence, were normal (Figure 1B). In addition, magnetic resonance imaging (MRI) of the brain and orbits with and without gadolinium were unremarkable.

Bilateral Central and Peripheral Vision Loss in an Otherwise Asymptomatic Woman

“…1,2 Diagnosis remains a challenge because of its variable presentation and fundus appearance, which may be initially normal or with minimal unrevealing alterations despite central vision loss and a severely decreased visual field. 1,2 Moreover, in contrast with previous reported cases, 3,4 the patient did not show any systemic symptoms that would have been helpful toward the diagnosis.…”