NANOSNET

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

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