Michael Cianca, OD

Title: Painless Acute Vision Loss in Young Patient Abstract: Acute, severe, painless vision loss is rare in young otherwise healthy patients. This case report follows the management and recovery of an atypical presentation of presumed Non- Arteritic Anterior Ischemic and assesses its differentials.

I. Case History • 29 year old Black male reports painless acute onset decreased vision, left eye, constantly for 3 days, associated with eye irritation and black . No history of injury, surgery, disease. Motor vehicle accident in 2014 with left-sided head injury and right-sided neck pain, MRI was unremarkable. History of elevated blood pressure without diagnosis of hypertension. No medications or other diagnosis reported. II. Pertinent findings • Clinical o VA: OD 20/30- OS CF @1M, PH NI ▪ 3 day follow up: OD 20/25, OS 20/70, 11 day: OD 20/20-, OS 20/40, 6 weeks: correctable to 20/20 OU o Entrance testing: show trace APD OS upon initial presentation, resolved at 6 week follow up, EOMs and CFF were unremarkable in both eyes. o Slit lamp: Lids, , , , angles all unremarkable in both eyes o Dilated fundus exam: ONH small and crowded OU, , vitreous, vessels, macula, and peripheral retinal all unremarkable • Laboratory studies: Recommended CBC and CRP to primacy care, not completed • Radiology studies: MRI of head and : unremarkable, (-) space occupying lesion • Imaging: o OCT ONH ▪ (6/16/17) OD: no RNFL thinning, slight elevation nasally OS: no RNFL thinning, elevation noted superior and nasal ▪ (8/03/17) OD: no RNFL thinning, slight elevation inferior, overall stable to previous OS: trace RNFL thinning temporally, reduced elevation from previous with new areas of mild thinning temporally. o OCT: MAC ▪ (6/16/17): OU normal foveal contour, no sub-retinal fluid o OCT: GCA ▪ (8/03/17): OU: no thinning present in all sectors o VF 24-2 and 10-2: ▪ (6/27/17): OD: unremarkable, OS: large central , more dense inf & nasal ▪ (8/03/17): OD: unremarkable, OS: large shallow depression, improved from previous III. Differential diagnosis • Primary: Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION) Michael Cianca, OD

• Others: Traumatic optic neuropathy, space occupying brain lesion, posterior ischemic optic neuropathy (PION), central serous , acute macular neuroretinopathy (AMNR) IV. Diagnosis and discussion • NAION (leading): Common patients above 50, however, numerous established cases in young patients (1). This patient had only one definite risk factor, crowded disk, and a possible second (history of elevated blood pressure without diagnosis of hypertension). The vision loss was uncommonly profound as the majority of cases have vision of 20/40 or better (1). The duration of vision loss varies case by case, but can last from days to weeks. Disk edema, typically present in NAION, was not evident upon fundus examination (2). OCT imaging reveals nerve elevation in two quadrants in the left eye, later resolved at 6 weeks. • Brain lesion: very rare cases may present with acute onset vision loss, MRI is crucial, tumor may infiltrate orbit or nerve; multiple sclerosis possible (1, 3, 4). • Traumatic optic neuropathy: most commonly from head injury, usually presents immediately to 4 weeks from injury, visual recovery prognosis good, high dose steroids may help (5,6) • Central serous retinopathy: unilateral 60% of cases, often reoccurs, typically young males (7) • PION: nerve appearance normal, typically follows significant blood loss and subsequent falling blood pressure, STAT MRI imaging during episode critical to diagnose (8,9) • AMNR: rare, more female, acute onset central or paracentral scotoma, possible redish-brown macular pigment changes, infrared fundus imaging reveals hypo-reflective macular lesions, OCT shows corresponding IS/OS loss (10) V. Treatment, management • There is no direct treatment for NAION. Ischemic Optic Neuropathy Decompression Trial revealed that direct surgical intervention is ineffective and likely dangerous (11). Instead, the underlying risk factors should be reduced if possible. Blood work, such as CBC, CRP, ESR, and platelets, should be ordered to rule out AAION (in an older patient) and identify possible etiology of anemia and sickle cell. To rule out a brain lesion, such as space occupying lesion, hemorrhage, or demyelinating disease, an MRI was ordered and the results were unremarkable. The patient was followed closely for 6 weeks with numerous OCT and VF. Vision steadily recovered to 20/20. If repeat occurrence, sleep study should be ordered as most NAION occurs overnight due to lack of perfusion of the nerve, often times due to obstructive sleep apnea (11). VI. Conclusion • Young patients presenting with sudden unilateral decreased vision should be examined promptly and thoroughly. It is crucial to have a relationship with primary care providers in order to coordinate management of blood tests, sleep study, and underlying systemic disease. Urgent imaging must always be obtained in the rare event pathology is located intraorbitally or intracranially. In office imaging, OCT and , are crucial in both identifying possible ocular etiologies and monitoring subsequent visual recovery. Michael Cianca, OD

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