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Subacute Vision Loss in a 37-Year-Old Man With a Rash

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 37-year-old man with no history of vision problems presented with subacute loss of vision in his right eye for 1 week. The patient described a paracentral scotoma that progressed to involve central fixation over the course of 3 days. Two weeks earlier, the patient and his children had developed malaise, low-grade fever, and a rash. He worked in the armed services and denied foreign travel, tick bites, or recent immunization. The patient had been evaluated by his primary care clinician and was referred to an ophthalmologist for further evaluation.

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Unilateral acute idiopathic maculopathy

D. Order coxsackievirus serologic testing

The subacute development of unilateral vision loss in an otherwise healthy young patient with recent viral illness initially led to a referral for possible optic neuritis. However, the lack of pain or relative afferent pupillary defect and irregular macular pigmentation raised concern for an inflammatory maculopathy, such as acute macular neuroretinopathy or unilateral acute idiopathic maculopathy (UAIM). Although these 2 entities both present with inflammatory changes of the RPE, the unilateral nature and more substantial acuity decline favored UAIM. Furthermore, characteristic unilateral gray-white retinal pigment changes with heterogeneous disruption of the photoreceptor layer and hyperreflective thickening of the apical RPE in the foveal region (Figure 2) on OCT confirmed the diagnosis of UAIM.

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Article Information

Corresponding Author: Andrew T. Melson, MD, Dean McGee Eye Institute, University of Oklahoma, 608 Stanton L. Young Blvd, Oklahoma City, OK 73104 (andrewtmelson@gmail.com).

Published Online: June 24, 2021. doi:10.1001/jamaophthalmol.2020.6586

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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