Hi Bob,
What a tough case. It sounds like you've done an appropriate and thorough work-up.
1) floaters: did exam or OCT sow a PVD?
2) left optic nerve: given the normal visual function this sounds like a recovered optic neuropathy, my top differential for this is prior injury from trauma, optic neuritis, or nutritional deficiency. The next mechanism I think about I call "pre-clinical optic neuropathy" and think about slowly progressive conditions that may cause OCT thinning before visual deficit such as glaucoma, MS, sarcoid, and perhaps certain nutritional deficiencies such as copper and folate. Lastly would be something genetic as we know that conditions like DOA can be highly variable and some genetic conditions have mild optic neuropathies.
One thing to remember is a patient with only one eye and has optic neuropathy has an optic neuropathy on all their optic nerves and thus is equivalent to a bilateral optic neuropathy.
I would guess that a patient like this with such an extensive history in the right eye has probably had VF and OCT in the left eye previously and reviewing them may offer some clues to progression vs stability. Is there any pattern to the GCC thinning?
If the nerve has been stable for 5+ years on review of records I might not do any further testing, if unclear if it has been stable it might be worth doing a CT chest and lab for soluble IL-2 receptor which has better sensitivity for sarcoid. Copper deficiency is very rare as an isolated nutritional deficiency especially in the setting of normal diet and no risk factors for malabsorption.
Best,
Drew
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Andrew Carey
Associate Professor
Wilmer Eye Institute, Johns Hopkins Medicine
Baltimore MD
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Original Message:
Sent: 03-24-2026 16:11
From: Robert Bellinoff
Subject: bilateral optic nerve pallor
Dear all,
I am writing to seek your expertise and would appreciate any suggestions on further workup for a patient of mine.
I am currently seeing a 63-year-old male who presented with floaters in his left eye. His pertinent history includes rheumatic fever as a child and a childhood injury to his right eye that required multiple surgeries (including cataract and glaucoma valves), which ultimately resulted in the right eye being NLP for years.
On examination, his vision was 20/20 OS with normal color vision and normal formal visual fields; the foveal decibel was 36. However, the OCT nerve shows 62 microns for the RNFL with GCC thinning, and the nerve appeared slightly pale. IOP was normal.
Regarding his systemic health, he underwent an aortic valve replacement and a CABG last week due to rheumatic fever damage; notably, my examination took place prior to this surgery. His CBC and lipid panel were normal. Other normal labs included ACE, RPR, FTA, Quantiferon Gold, TSH, B12, folate, MOG, and Aquaporin 4. Pertinent positive labs included an ANA with a titer of 1:40, as well as positive SSA and SSB.
An MRI of the brain and orbits revealed mild atrophy of the optic chiasm, severe optic atrophy of the right eye due to the prior injury, and mild atrophy of the left optic nerve.
I am unsure if there are any other necessary tests to perform at this stage or if I should simply continue to follow him for now. Your suggestions and insights would be very welcome.
Thank you very much for your time and assistance.
Best regards,
Robert Bellinoff
Robert Bellinoff, MD
Division Head, Eye Department, Mercy Medical Group
Site Medical Director of Midtown Medical and Surgical Specialties
Mercy Medical Group
3000 Q Street
Sacramento, CA 95816
(916) 733-3311 (O)
(916) 733-3307 (F)
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