Dear colleagues,
I would appreciate any advice you can give me on this patient. She is a 57-year-old female with no past significant medical history other than being on thyroid medication. She is not diabetic, hypertensive, or hyperlipidemic. I saw her yesterday for the first time. She noticed a "smudge" in the vision of her right eye about 5 days ago and thought it was glasses. No pain at all . Two days later, she realized her vision was poor even without glasses. She denies headaches, flashes, or floaters, as well as jaw claudication, hip or shoulder pain. She does have fibromyalgia and reports no scalp tenderness.
When I saw her yesterday, her vision in the right eye was described as just seeing white in front of her, unable to see fingers in any quadrant, and unable to see a red cap to determine color vision. Extraocular movements were intact (EOMI), no pain with EOM and she presented with a 2+ afferent pupillary defect (APD) on the right eye. Her left eye had 20/20 vision and a not a disc at risk. Optical coherence tomography (OCT) of the optic nerves was normal in both eyes, with nerves appearing to have 0.2 cups of good color bilaterally, and intraocular pressures were within normal limits.
At this point, my diagnosis is Posterior Ischemic Optic Neuropathy (PION). The challenging aspect of this case is that she had an MRI with contrast a few months ago for her fibromyalgia and had a severe contrast reaction requiring resuscitation. Therefore, I have ordered an MRI without contrast of the orbits to evaluate the sinuses and surrounding area, as well as a sed rate, CRP, aquaporin antibody test, MOG antibody test, RPR and FTA-ABS, and a carotid ultrasound. Empirically I started her on 60mg of prednisone as well.
Given her history of a severe contrast reaction, I am wondering how else to further work her up since a contrast-enhanced MRI of the orbits is not an option. Thank you for your insights.
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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