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  • 1.  Bilateral Visual Decline Post-Cataract Surgery in a 64-Year-Old Female

    Posted 07-15-2025 09:48
    Dear All，
    I have a patient and need suggestions. Any opinions are welcome.
    Female, 64 years old, underwent bilateral cataract surgery one and a half months ago, with a postoperative BCVA of 20/30. She had hypertension and DM, without history of cancer. One month ago, she suddenly experienced a simultaneous decrease in vision in both eyes, without pain on eye movement or headache. She complains of vision like looking through fog and things appearing brighter, but there is no significant photophobia or obvious dimming of vision. At that time, the visual acuity recorded by the local doctor was 20/200.
    One month later, I saw the patient. She reported that her vision had improved somewhat but was still not clear. The BCVA was found to have recovered to 20/40. Color vision: 0/8, RAPD was negative. The anterior chamber was quiet. No cells in the vitreous. The optic nerves and retina were normal. Autofluorescence was normal. Static perimetry showed a small central scotoma in the left eye, and a larger central scotoma and inferonasal scotoma in the right eye. MRI of the brain and orbits w/o contrast was normal. Macular OCT line scan (inner retina and photoreceptors, RPE) was normal. The GC-IPL (Zeiss) was symmetrically thinned by 60 microns in both eyes, and the thickness of RNFL in all quadrants was normal. MfERG showed a severe decrease in macular response. Full-field ERG showed a significant decrease in light adaptation responses in both eyes, and a mild decrease in all dark adaptation responses.
    What further tests are needed? What could be the possible diagnosis?
    Thanks!


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    Yan
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  • 2.  RE: Bilateral Visual Decline Post-Cataract Surgery in a 64-Year-Old Female

    Posted 07-15-2025 13:16
    From the story with improvement after brief bilateral visual loss and with residual central scotoma this may be nutritional related , Vitamin B optic neuropathy , but I would ask for full immunological work up , second this could be paraviral , so ask of history of flu like illness before diminution of VA 





  • 3.  RE: Bilateral Visual Decline Post-Cataract Surgery in a 64-Year-Old Female

    Posted 07-15-2025 13:40
    This is wild. Could the inflammation from
    Cataract surgery igniting some kind of auto-immune maculopathy? I’d probably send the panel.


    Original Message


  • 4.  RE: Bilateral Visual Decline Post-Cataract Surgery in a 64-Year-Old Female

    Posted 07-15-2025 19:22

    I agree that it is worth exploring a maculopathy, but would caution the interpretation of the commercial antiretinal antibody panels.  We found that up to 94% of patients without an autoimmune retinopathy had positive antiretinal antibodies.  Chen JJ, McKeon A, Greenwood TM, Flanagan EP, Bhatti MT, Dubey D, Pulido JS, Iezzi R, Smith WM, Sen HN, Gordon LK. Clinical utility of antiretinal antibody testing. JAMA ophthalmology. 2021 Jun 1;139(6):658-62.

    Best,

    John




    Original Message


  • 5.  RE: Bilateral Visual Decline Post-Cataract Surgery in a 64-Year-Old Female

    Posted 07-15-2025 13:52

    For bilateral central scotomas, Steve Newman taught the mnemonic MITCH. 

    M (metabolic: vitamin deficiencies)

    I (infectious, inflammatory, ischemic): Interestingly, while most optic neuropathies are an I, bilateral central scotomas are very rarely an I

    T (toxic: ethambutol, linezolid, etc)

    C (compression: much more common to be unilateral so quite rare for bilateral central scotomas)

    H (hereditary: LHON, DOA).

     

    Are there any changes of the ellipsoid zone on OCT or autofluorescence to suggest a maculopathy?  If not, with the diffuse GCL thinning and intact RNFL with fairly acute onset, I would have LHON on the ddx (in addition to the vitamin deficiency suggested by Sherif).  I think there can be mfERG changes in LHON.  The improvement over 1 month is odd, but perhaps this is just variability from looking just eccentrically to central fixation.

     

    Best,

    John

     




    Original Message


  • 6.  RE: Bilateral Visual Decline Post-Cataract Surgery in a 64-Year-Old Female

    Posted 07-16-2025 01:56
    Was OCT only done one month post surgery? In that case, there could have been macular edema that improved over time. That can explain the improvement in VA.

    Would definitely check B12 and others from the group, Folic acid, etc.

    Michael


    --

    Michael Paul M.D

    Eye diseases and Surgery

    Director Emeritus

    Ophthalmic Plastic and Reconstructive Surgery

       ,Orbital and Lacrimal Surgery Service 

    Neuro-Ophthalmology

    Dept  of Ophthalmology

    Edith Wolfson Medical Center

    Holon, Israel

    972-3-5049554

    Fax: 972-3-5018703



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  • 7.  RE: Bilateral Visual Decline Post-Cataract Surgery in a 64-Year-Old Female

    Posted 07-16-2025 19:20

    With bilateral painless visual loss, central scotoma, profound OCT GCC thinning  but preserved RNFL, I would include Leber's in the differential. In addition to the three classic mutations, fewer than a dozen other pathogenic variants have been identified. They can lead to varying degrees of visual loss.

     

    I had a patient who lost vision in one eye a few days following cataract surgery, which ultimately turned out to be GCA. This case does not strongly suggest GCA.

     

    Best,

    Judy

     






  • 8.  RE: Bilateral Visual Decline Post-Cataract Surgery in a 64-Year-Old Female

    Posted 07-17-2025 10:52
    Edited by Yan Yan 07-17-2025 10:59
    Thank you very much for all your replies. I will order more tests.
    The patient did not have any history of fever or flu prior to vision loss. After cataract surgery, the patient had many examinations locally, including OCT line scan, all of which showed no abnormalities. The cataract surgery went very smoothly, so it is not a problem with the surgery. However, I am hesitant to differentiate between optic nerve diseases and retinal diseases.
    I once had a patient with cone dystrophy (POC1B gene) who had symmetric bilateral GCC thinning and temporal RNFL thinning with large central scotoma. The OCT pattern of that case fooled me. But in that case, the macular line scan showed abnormalities in IS/OS and the patient had obvious photophobia. The macula line scan of this patient was normal.
    Another question: Is central scotoma common in autoimmune retinopathy?
    I agree with Dr. Chen's opinion that the improvement of vision may be due to eccentric fixation.



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    Yan
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    Original Message


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