A 63-Year-Old Woman With Decreased Vision

Rod Foroozan, MD

Disclosures

April 03, 2018

Clinical Presentation

A 63-year-old Japanese woman reported decreased vision in the superior visual field of the right eye. She said that a shadow appeared in her right eye perhaps a month before, but she was not certain of the exact date of onset of these visual symptoms, which had remained stable since then. She noted no problems in the left eye.

She experiences migraine headaches, for which she takes acetaminophen as necessary. She is not currently taking any prescription medication. She had no history of pain in the jaw with chewing, weight loss, or scalp tenderness.

She drinks alcohol occasionally and does not use tobacco. There is no family history of vision loss.

Visual acuity was 20/20 in both eyes. Color vision with Ishihara pseudoisochromatic plates was 10/10 in both eyes. Pupils were slightly sluggish in the right eye and brisk in the left eye with a right relative afferent pupillary defect. Automated perimetry showed a superior altitudinal defect in the right eye and was full in the left eye (Figure 1). Intraocular pressure (IOP) was 18 mm Hg in the right eye and 15 mm Hg in the left eye.

Figure 1. Automated perimetry showed a superior altitudinal defect in the right eye and a full field in the left eye.

Slit-lamp examination of the anterior segment showed nuclear sclerosis in each eye. Funduscopic examination showed no evidence of optic disc pallor or edema (Figure 2).

Figure 2. Funduscopy showed optic disc cupping in the right eye and a normal optic disc in the left eye. Note the asymmetry in optic disc cup size between the two eyes and the inferior focal loss of neuroretinal rim in the right eye.

Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) showed decreased measures in the right eye, particularly inferiorly, compared with the left eye (Figure 3); this correlated to the optic disc cupping and visual field loss. OCT of the macula showed no evidence of retinopathy (Figure 4).

Figure 3. OCT of the RNFL showed decreased measures in the right eye, particularly inferiorly, when compared with the left eye.

Figure 4. OCT of the macula showing no evidence of retinopathy.

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