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A woman in her 20s was referred by the optician to our acute and emergency department for suspected optic neuritis in the right eye. She reported a sudden onset of photopsia and visual disturbances described as “fixed swirl circles” in the central vision of both eyes noticed on awakening 5 days prior and persisting since that time. Her medical history included migraine and polycystic ovaries. She had a flulike episode 1 week prior to the onset of symptoms. The patient was taking oral contraceptives and denied the use of recreational drugs. Ocular movements were full but the patient reported pain and discomfort during movements of the right eye. Pupils were equal and reactive to light and there was no afferent pupillary defect. Best-corrected visual acuity was 20/20 OU; color vision was 17/17 OU on Ishishara plates. The anterior segment was unremarkable and intraocular pressure was 14 mm Hg in both eyes. Dilated fundus examination revealed a healthy optic disc and no obvious abnormalities at the macula of both eyes. Near-infrared reflectance imaging and spectral-domain optical coherence tomography (OCT) scans of the right eye are shown in the Figure.
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Acute macular neuroretinopathy (AMN)
B. Observe the patient
Sudden-onset paracentral scotoma, good visual acuity, and the presence of wedge-shaped paracentral hyporeflective lesions on infrared reflectance imaging associated with hyperreflectivity of the junction of the outer plexiform layer and the outer nuclear layer on OCT were consistent with AMN. Observation (choice B) was the appropriate next step for this case. Fluorescein angiography (choice A) would not be the preferred answer as the next step because AMN is typically not detected on fluorescein angiography. Magnetic resonance imaging of the brain (choice C) was not recommended as the next step because diagnosis of AMN per se does not require brain imaging unless there are symptoms and/or signs suggestive of central nervous system involvement. There is no proven treatment for AMN; thus, treatment with oral corticosteroids (choice D) was not indicated.
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Corresponding Author: Giuseppe Casalino, MD, FEBO, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London EC1V 2PD, United Kingdom (email@example.com).
Published Online: February 7, 2019. doi:10.1001/jamaophthalmol.2018.5919
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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