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Bilateral Hemorrhagic Optic Disc Edema in a Middle-aged Man

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

A 49-year-old man with a history of diabetes, hypertension, intravenous drug abuse, and multiple sexual partners presented to the emergency department with painless vision loss in both eyes for 10 days, left eye worse than right eye, and photophobia in both eyes. His visual acuity was count fingers OD and 20/70 OS. Intraocular pressure was 20 mm Hg OD and 16 mm Hg OS. There were 1+ (10-12 cells/high-power field) anterior chamber cells in both eyes with very hazy posterior pole details in the right eye and minimal vitreous haze in the left eye. There was a hazy view to the posterior pole in the right eye with disc edema and multiple flame hemorrhages surrounding the nerve. Examination of the posterior pole in the left eye revealed partial obstruction of all vessels and a complete halo on the disc with numerous flame hemorrhages emanating from and surrounding the optic nerve, along with a few dot blot hemorrhages within the macula (Figure). His blood pressure was 173/137 mm Hg, but the rest of his vital signs were normal.

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Syphilitic panuveitis and optic neuritis

A. Obtain HIV and syphilis serology results

In this patient with hemorrhagic optic neuritis and evidence of panuveitis, infection must first be ruled out before initiating any systemic corticosteroids (choice A). A patient with a history of drug use and many sexual partners further supports ruling out an infection, particularly syphilis and HIV. Idiopathic demyelinating optic neuritis is a common cause of optic nerve edema with abnormal visual function in patients younger than 50 years, although it typically does not present with panuveitis.1 Therefore, beginning methylprednisolone would not be appropriate without proper systemic workup (choice B). Cytomegalovirus optic neuritis should be on the differential diagnosis for any patient with substantial risk factors for HIV/AIDS, although there were no signs suggestive of cytomegalovirus retinitis on examination and therefore treatment with foscarnet is not appropriate (choice C). Intracranial imaging may be warranted in the evaluation of papilledema, but magnetic resonance imaging of the brain would be more appropriate than computed tomography of the head, as it better detects optic neuritis and cerebrospinal fluid outflow obstructions (choice D).1 Additionally, his subsequent blood pressure measurements lowered and his initial reading was felt to be transient in the setting of an emergency visit, and thus, hypertension was not felt to be the causative etiology.

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Article Information

Corresponding Author: James P. Dunn, MD, Mid Atlantic Retina, Retina Service of Wills Eye Hospital, 840 Walnut St, Ste 1020, Philadelphia, PA 19107 (jpdunn@willseye.org).

Published Online: January 13, 2022. doi:10.1001/jamaophthalmol.2021.3419

Conflict of Interest Disclosures: None reported.

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

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