NANOSNET

I saw Mr SM 36yo new patient for sequential altitudinal vision loss at 20yo and then 36yo. Was wondering if you would label him as optic neuritis and put him on long term immunosuppression . 

Background:  nil

Ocular: nil

Fhx: nil fhx migraines. Father Addison's disease. Brother haemolytic uremic syndrome. Mother parkinsons. Nil vision loss. 

Medications: nil.

Social: occupational health. Home with partner and 2 kids. Nil smoker. Occasional alcohol

 

2009 Age Was working at Crown Casino and had blurring os and thought he had a hair in the way os. 2 days later went to GP and still had the stripe os. 5 days from Crown woke up with inferior vision loss od. Had mild tension around the eyes and uncomfortable to move eyes in extremes. Then went to a GP and then Hospital 23Oct2026. Maintained visual acuity of 6/5 od and os. Notes reports inferior field defect od superotemporal quadrant loss os. ophthalmology notes bilateral disc swelling ou . He was diagnosed with bilateral optic neuritis. His vision loss never progressed and never improved with IVMP steroids. MRI brain 26Oct09 and whole cord 19Nov09 normal. NMO -ve. Had repeat MRI brain and spines in 2010, 2011, 2012 and then 2013. No change and never any lesions to suggest chronic ischaemic change or demyelination. 

Had persistent inferior field defect od and stripe of vision os since the initial onset.

 Seen in 2016 and NMO and MOG -ve

26Dec25 was walking down stairs in Queensland and noticed had a cloud inferiorly os and uncomfortable to move the eyes. Went to Sunshine hospital had IVMP and had a lumbar puncture. Glucose 4.2 Protein 380 (150-500) wbc 1 rbc 2 culture negative.

Lupus  -ve, folate 46.5 b12 474, syphilis -ve, quantiferon -ve, strongyloides -ve, HIV -ve, HTLV -ve, CMV -ve EBV IgM and VZV IgM-ve, RF <20 anti ds DNA -ve ANCA -ve, ANA -ve. SPEP -ve.  Had disc swelling os. Went on prednisolone for 3 weeks post. Swelling started to reduce after a week.

NMO -ve MOG -ve CSF MOG -ve

OPSM

21Jan26 HVF inferior field defect od superior arcuate with an island inferonasally loss os

21Jan26 OCT RNFL 68um od 97um os

Started mycophenolate 2g daily. He took it for 3 weeks and stopped because of flu like symptoms and found it inconvenient to take medication.  You organised CT Chest and this showed no sarcoidosis. Completed on 8Apr2026.

 

Apr2026 was reading a computer screen and had depth perception loss, letters missing, swirly lines. Could see with eyes close. Didn't evolve. Was in both eyes. Went to lie down for 15-20 minutes and was sensitive to light and then got frontal headache. No residual loss. Took Panadol.

3 days ago, similar episode. Both episodes were post gym work out. 1-2 hours post workout.

No day time napping. Snores only if on his back.

 

Exam: BP 119/72 HR 62

VA 6/5sc od 6/5sc os CP 7/7 ou, confrontational visual fields inferior field defect od – cannot detect movement inferiorly od, blurring inferiorly os – counts fingers normally. Describes stripe of vision loss superiorly os

Pupils 3mm ou in light 5mm ou in dark. No RAPD. Fundoscopy: pale disc od inferior pale os – disc at risk os.

Full eye movements

 Investigations: 

Sorry I dont have any OCTs in colour. I happened to see him in a room that doesnt have this equipment

Impression: 2009 describes sequential sudden onset altitudinal vision loss os then od with no progression and no improvement with steroids. 2025 again sudden onset altitudinal vision loss os with no progression and no improvement of steroids. Given he has disc at risk I cannot go past NAAION as a diagnosis. This is altitudinal, sudden onset, typically painless – but can have pain in 10-15% and doesn't respond to steroids.  

 

 Plan: fasting cholesterol, TAG, HDL, LDL, fasting glucose.

Will discuss with my colleagues about him.

Sherif 

Sherif 

Thanks for replying all. 

This week I had a young women , a house wife from the southern rural area of Egypt she has a disc swelling with lower actuate rather than altitudinal but the disc had the typical picture on NA ION rather thank papillitis , I have given her steroids and all vasculitis profile came negative , I noticed she is so thin and under weight , only thing relevant is hypotension, while asking about her nutritional history a quarrel erupted between her and her husband starting with I told you what you are doing is wrong and will destroy your health , she has some sort of anorexia in which she eats solely a specific type of old Egyptian cheese with enormous amounts of heavy black tee , when I told her that her husband may be right I found my self in the middle of a family clash that continued even outside the clinic ���� but I think at last I convinced her to go to a nutritionist to modified her diet 

This example I meet you can say once a month or so when nutrition is a factor not only B12 but general patterns of bizarre nutritional patterns 

Thank you for the interesting case Sir 

Sherif