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Patient Presentation: A 23-year-old obese female was diagnosed with idiopathic intracranial hypertension (IIH) and referred to neurosurgery for ventriculoperitoneal shunt. A baseline ocular examination was performed prior to the procedure.

On examination, vision was 20/200 in the right eye, and 20/40 in the left eye. There was a right relative afferent pupillary defect. Slit lamp examination was normal.

A dilated fundus examination was performed demonstrating the following:

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Neuro-Ophthalmology

Case 33

Patient Presentation: A 67-year-old man was referred to a tertiary neuro-ophthalmology clinic for suspected left optic neuropathy. He reported a 3-month history of blurred and distorted vision in his left eye, and a central scotoma that fluctuated when laying flat/bending forward. He denied pain, redness/photophobia, flashes/floaters, or peripheral field defects. Ocular history was significant for non-granulomatous anterior uveitis (work-up negative) and cystoid macular edema with an associated previous episode of optic nerve head edema, which was treated with topical corticosteroid drops 5 years prior.

Visual acuity was 20/20 OD and 20/60 OS. There was a brisk left RAPD. The appearance of the nerve and visual fields are shown below:

Question 1: Describe the appearance of the optic nerves.

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OCT ONH/RNFL imaging was performed and is shown below:

Next, OCT 5-line raster images over the optic nerve heads were taken and are shown below:

Question 2: Based on the OCT, what is the most likely preliminary diagnosis?

A. Myelin Oligodendrocyte Glycoprotein Associated Optic Neuritis

B. Neuromyelitis Optic (Devic’s Disease)

C. Multiple Sclerosis

D. Vitreopapillary Traction

Question 3: If this patient was asymptomatic and had no previous medical/ocular history, what further testing would be required?

A. MRI Orbits with contrast

B. MOG/NMO antibodies

C. MRI Brain with Venography

D. No further testing required

References:

Gabriel RS, Boisvert CJ, Mehta MC. Review of Vitreopapillary Traction Syndrome. Neuroophthalmology. 2020;44(4):213-218. Published 2020 Feb 26. doi:10.1080/01658107.2020.1725063
Katz B, Hoyt WF. Gaze-evoked amaurosis from vitreopapillary traction. Am J Ophthalmol. 2005;139(4):631-637. doi:10.1016/j.ajo.2004.10.045

Learning Objectives:

To identify signs of vitreopapillary traction on OCT imaging.
To include vitreopapillary traction on the differential diagnosis of unilateral optic nerve disc edema and recognize its potential symptoms.

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