Presentation
A 25-year-old Caucasian man presented after noticing decreased visual acuity in his right eye. He had accidentally hit his head on a bookshelf one week prior, but had no symptoms or other significant injury at the time.
Medical History
The patient's past medical history was significant for a remote history of trauma, resulting in a liver laceration and leg fractures. He did not have a known history of diabetes or hypertension. His only medication was oxycodone-acetaminophen as needed for back pain. He smoked one-half a pack of cigarettes per day and drank alcohol occasionally. His family history was significant for macular degeneration and glaucoma. His review of systems was otherwise negative.
Examination
Best-corrected visual acuity was 20/30 in the right eye and 20/20 in the left eye. A trace relative afferent papillary defect was present in the right eye. Extraocular movements were full in both eyes, and the patient denied pain. The patient read 14/15 Ishihara color plates correctly with the right eye, and 15/15 with the left. Intraocular pressures and anterior segment examinations were normal. Dilated fundus examination of the right eye was significant for mild hyperemia and elevation of the optic nerve (See Figure 1). The posterior exam of the left eye was unremarkable.
The patient was referred to neuro-ophthalmology for workup of a potential optic neuropathy. Humphrey Visual Field tests were obtained at presentation and three weeks later (See Figure 2). MRI imaging of the brain and orbit was performed. The patient was sent for blood work, including Lyme titers, ANA, RPR, FTA, ACE level and ESR. Bloodwork and MRI were all found to be within normal limits.
