A 49-year-old Caucasian female presented to the Wills Eye Hospital emergency room with progressively worsening eye pain and decreased vision OU over the past three months. The patient reported photophobia, headache, scalp tenderness and pain with eye movement. She denied a change in appetite or weight.
Her past medical history was significant for metastatic melanoma, panhypopituitarism, hypertension and obesity. Metastatic melanoma had been diagnosed 16 months prior, and she had undergone wide local excision and treatment with systemic therapies including ipilimumab and vemurafenib. Her clinical course was complicated by local recurrence and bilateral lymph node involvement. At the time of presentation, she was enrolled in a clinical trial investigating the use of pembrolizumab with or without talimogene laherparepvec versus an oral placebo. She denied alcohol intake and smoking.
Her medications at presentation included bisoprolol-hydrochlorothiazide, buproprion, cetirizine, citalopram, lorazepam, zolpidem, naproxen-esomeprazole, prednisone, promethazine, diphenhydramine, docusate, fluticasone, levothyroxine and pembrolizumab (Keytruda) +/- talimogene laherparepvec.
On examination, visual acuity was 20/50 in the right eye with pinhole improvement to 20/30, and 20/30 in the left eye with pinhole improvement to 20/20. Both pupils were equal, round and reactive to light without relative afferent pupillary defect. Intraocular pressure was 16 mmHg OU, motility was normal and confrontational visual fields were full. Color plates were full bilaterally. Anterior slit lamp examination was unremarkable. Fundus examination revealed bilateral optic nerve edema with associated hemorrhages. The macula and peripheral retina appeared normal in both eyes.Click here for diagnosis, workup and discussion.