Isolated Optic Neuropathy as the Presenting Sign of Neurosyphilis

Background: Detection and treatment of syphilitic ocular disease without a known history of syphilis is often difficult due to its varied presentations. Early diagnosis and treatment are the key to reducing risk of permanent vision loss, particularly with optic nerve and retinal manifestations. Case Report: This case report describes a 44 year-old male who was diagnosed with neurosyphilis through his work-up for unilateral optic neuropathy. Conclusion: This report illustrates the importance of including syphilis lab testing in the setting of optic nerve edema. Syphilis should be considered in any inflammatory ocular disease, especially in patients with atypical presentations and high-risk populations. As the incidence of syphilis continues to rise, it is important that eye care providers play a vital role in prompt diagnosis to decrease the risk of vision loss and limit further spread of the disease

Bilateral, Full-thickness Macular Holes While Undergoing Chemotherapy

Background: Bilateral, full-thickness macular holes are a rare condition that can substantially affect quality of life. Macular hole diagnosis and treatment is key for these patients. Case Report: A 71 year old Caucasian male presented with a chief complaint of distance blur in both eyes, worsening over the past 1-2 weeks. He had no diagnosis of diabetes. He added that his prostate cancer had spread and that his last treatment ended 9 days ago. He was ultimately diagnosed with bilateral, full-thickness macular holes. Referral to a retinal specialist for surgical management yielded good results. Conclusion: This is the first case report documenting bilateral macular holes in a patient with these systemic meds to date. More research on any potential ocular side effects of these medications is recommended

Bilateral Optic Disc Drusen with Neuroretinitis

Background: Neuroretinitis is an inflammation of the posterior pole of the eye, resulting in optic disc edema and macular star formation. Systemic conditions associated with these findings include tuberculosis, toxoplasmosis, syphilis, lyme disease, toxocariasis, mumps, herpes simplex, and cat scratch disease. This case illustrates diagnosis and treatment for a patient with neuroretinitis complicated by preexisting vision loss. Case Report: A Caucasian male in his 40’s presented to the eye clinic for an emergency appointment with complaints of constant blurry vision, especially inferiorly upon awakening, in his right eye for the past two weeks. His ocular history included optic disc drusen in both eyes with profound peripheral vision loss in the left eye. The patient’s systemic history included cluster headaches and sleep apnea. Entering visual acuities were 20/150- OD and 20/20 OS. Additional medical history questioning revealed the recent adoption of a kitten. Conclusion: This case describes the diagnosis and treatment for the rare condition of neuroretinitis secondary to a Toxocara infection. While cat scratch disease was initially suspected, detailed laboratory testing identified the true, and more rare, causative infectious agent. A variety of differential diagnoses were ruled out through laboratory and imaging studies. Consultations with neuro-ophthalmology and infectious disease specialists were exceedingly valuable in contributing to a positive outcome for this patient. This patient’s preexisting ODD with vision loss heightened the concern to preserve the patient’s remaining vision and further added to the complexity of this challenging case. The importance of medical history questions regarding animal contact also proved vital for accurate diagnosis and treatment of this sight threatening condition

Minimum Rim Width and Lamina Cribrosa Depth in Non-Glaucomatous and Glaucomatous U.S. Veterans

Purpose: Assess the utility of the MRW and lamina cribrosa depth measurements for detecting differences between non-glaucomatous and glaucomatous U.S. Veterans. Compare inter-eye differences of individuals with glaucoma. Method: 38 subjects were recruited per group: Group 1 included one eye of non-glaucomatous participants, and Group 2 included each qualifying eye of participants with glaucoma. Analysis compared Group 1 with the more affected eye only of Group 2 participants, and separately between the more and less affected eyes of group 2 participants. MRW measurements were obtained with Heidelberg Eye Explorer© (HEYEX). Average lamina cribrosa depths were measured manually utilizing HEYEX. Results: 26 subjects from Group 1 and 33 subjects from Group 2 were included. A significantly thinner MRW was found in glaucomatous eyes vs. non-glaucomatous eyes (210 µm vs. 309 µm; P \u3c .001). The normative database in HEYEX had an 85% sensitivity and 92% specificity to detect glaucomatous nerves. Among the 27 participants in Group 2 who had both eyes tested, eyes with more advanced visual field loss showed significantly thinner global MRW compared to fellow eyes (203 µm vs. 224 µm P = .03). Lamina cribrosa depths were non-significantly deeper in glaucomatous vs. non-glaucomatous eyes (476 µm vs. 429 µm P = .17). Conclusions: The MRW parameter differentiates between glaucomatous and non-glaucomatous optic nerves. Lamina cribrosa depths were non-significantly deeper in glaucomatous vs. non-glaucomatous participants. Post-hoc inter-eye data analysis suggested that inter-eye differences in gMRW values of glaucomatous eyes reflect asymmetric damage as correlated with the visual fiel

Presumed Diffuse Unilateral Subacute Neuroretinitis: A Review Supported by a Unique Case

Diffuse unilateral subacute neuroretinitis (DUSN) is a rare, sight-threatening inflammatory condition caused by a nematode. It typically affects healthy children and young adults. Various nematodes have been implicated, including those that originate from dogs and raccoons. Late stage findings include optic nerve atrophy, retinal arterial attenuation, “retinitis pigmentosa-like” retinal pigmentary changes, and central and peripheral vision loss. We present a case study of long-standing DUSN. The combination of optical coherence tomography (OCT) and visual electrophysiology testing proved invaluable in establishing a presumptive diagnosis of this rare condition

A Reactivation of Ocular Toxoplasmosis during Pregnancy

Background: Toxoplasma gondii is a parasite estimated to affect over 500 million people worldwide. The feline is the definitive host for the parasite and infection may be acquired or congenital via maternal transmission. Humans may acquire the infection by ingestion of raw or undercooked meats and vegetables, contaminated water, or exposure to infected cat feces. The infection is often benign, self-limiting, and asymptomatic for humans, but potentially life threatening to infants or the immunocompromised patient. Case Report: A 22 year-old Caucasian female, pregnant at 12 weeks gestation, presented to the optometry service with acute symptoms of hazy vision and a new gray stationary blind-spot in the inferior field of vision of the right eye. Clinical picture led to diagnosis of reactivated ocular toxoplasmosis. Conclusion: Ocular toxoplasmosis primarily affects the retina, producing a retinochoroiditis with resultant scarring and potential blindness. Treatment with a combination of antibiotics and steroid may be required. Allergy history and current pregnancy were important factors to consider when determining treatment of our patient

Lyme Disease Neuroretinitis: A Case Report and Review of Immunologic Workup

Background: Lyme disease is an infection caused by a bacterial spirochete of the borrelia genus. The human vector is from a tick bite by an infected tick of the ixodes genus, commonly referred to as the deer tick or black legged tick. The incidence of Lyme disease is increasing in the United States. Once infected, Lyme disease manifestations usually depend on the stage of infection with late stage infection often causing debilitating illness.1 Case Report: Neuroborreliosis refers to borrelia, causing neurological infection and can occur as acute or late manifestation of Lyme disease. Neuroretinitis is a rare but reported manifestation of neuroborreliosis. Lyme diagnosis requires a two-step serologic test to meet CDC guidelines for Lyme confirmation.1 Testing may be negative early in disease but may turn positive as the disease progresses. Conclusion: Presented is a case where treatment decisions were made based on equivocal Lyme testing results

Ocular Manifestations of Septo-optic Dysplasia

Background: Septo-optic dysplasia (SOD) is a congenital deformity of the brain which can result in neurologic, systemic, and physical malformation.Due to the proximity of these deformities to the optic chiasm and optic nerves, ocular manifestations are common. Case Report: A 28-year-old male with a long-standing history of reduced vision presented for a routine eye examination. Upon examination he was found to have an afferent pupillary defect, bilateral optic nerve pallor with corresponding nerve fiber layer thinning by optical coherence tomography. Humphrey visual field testing revealed a bi-temporal visual field defect. Neurological imaging was obtained with a subsequent diagnosis of Septo-optic dysplasia (SOD). Conclusion: Our patient had bilateral optic nerve hypoplasia and an absent septum pellucidum without endocrine abnormalities. This case reiterates the importance of accurate diagnosis of amblyopia only in the absence of ocular and neurological disease. This review also highlights the importance of imaging in instances of unexplained optic atrophy

Case Report: The Dilemma of Imaging an Isolated Sixth Nerve Palsy

Background: Traditionally, eyecare providers employ a wait-and-see approach with respect to older patients presenting with a presumed vasculopathic isolated sixth nerve palsy. However, given review of recent literature and the potential of morbidity in these patients, acute neuroimaging should be strongly considered. Eyecare providers are often faced with challenging decisions when patients present with acute isolated oculomotor nerve palsies. This case highlights the diagnostic dilemma of an older patient with significant vasculopathic risk factors who presents with an isolated sixth nerve palsy. For patients older than 50, a vasculopathic etiology is the most likely cause, however, a small but significant percentage of these patients may suffer from a more ominous condition such as, giant cell arteritis, intracranial mass, or aneurysm. As evidenced by our case, acute neuro imaging should be considered in all isolated sixth nerve palsies. Case Report: A 69- year old Caucasian male presented to the VA Connecticut Healthcare System with new onset diplopia. The patient reported a recent history of mild orbital pain and headaches. Evaluation revealed an isolated left sixth nerve palsy. A microvascular etiology was presumed given his strong vasculopathic history. One week later the patient returned to clinic with a new left pupil-sparing third nerve palsy in addition to his original left sixth nerve palsy. Magnetic resonance imaging of the brain and orbits with and without contrast revealed a left cavernous sinus mass. The patient was transferred to the Smilow Cancer Hospital at Yale-New Haven and received gamma knife radiosurgery for the presumed neoplastic lesion. Conclusion: Although support can be made for both a “wait-and-see” approach and acute diagnostic imaging, our case highlights the benefits of early imaging. Appropriate acute neuro imaging in patients with presenting isolated sixth nerve palsies can be lifesaving

Sagging Eye Syndrome--an Overlooked Diagnosis

Abstract Background: Sagging Eye Syndrome (SES) is a relatively unknown cause for binocular distance diplopia. SES presents with an acquired comitant or non-comitant small angle esotropia and/or hypotropia commonly occurring in the elderly population. Inferior displacement of the lateral rectus secondary to age-related degeneration of orbital connective tissue and extraocular muscles appears to be responsible for the ocular misalignment. SES patients often present with new onset or progressively worsening distance diplopia, typically warranting neuroimaging. However, through understanding SES, eye care practitioners may identify these cases, avoiding unnecessary imaging studies. Case Report: A 90-year-old male presented with complaints of intermittent horizontal diplopia at distance despite being prescribed prism for presumed decompensating phoria at his most recent eye exam. The patient noted progressing diplopia which appeared worse in right gaze. Full binocular examination revealed a non-comitant esotropia worse at distance than near. External exam revealed prominent deep superior sulci, blepharoptosis, and orbital fat loss bilaterally. Due to the progressive nature and incomitancy of the diplopia, a neuro-ophthalmology consult was obtained, and the patient was diagnosed with SES. A clinical diagnosis was made based on history, adnexal features, and motility patterns distinct to SES, obviating the need for confirmatory imaging. Conclusion: Patients presenting with new onset diplopia secondary to undiagnosed SES may prompt expensive and time-consuming investigations. It is critical that eye care practitioners accurately recognize the signs, symptoms, and clinical features of SES to avoid unwarranted imaging and patient anxiety. This case report reviews the clinical presentation, exam findings, and distinct picture of SES required for diagnosis and necessary to differentiate this condition from more serious neurologic conditions. Treatment and management will be discussed. Note: No identifiable health information was included in this case report. Written informed consent was obtained for patient images