Neuro-Ophthalmology

Case 22

Patient Presentation: A 32-year-old female patient was referred by an optometrist to a tertiary general ophthalmology clinic for concern of unilateral disc edema. The patient noticed mild blurred vision in her left eye and went to see her optometrist. She denied previous medical history or ocular history. Distance visual acuity was 20/20 OD and 20/20 OS with IOP wnl; there was no RAPD. Anterior segment examination showed a rare cell in the anterior chamber. Dilated examination demonstrated 1+ vitreous cells OS and the following:

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OCTs of the RNFL and macula OU were conducted and are shown below:

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Question 1: Which of the following best describes the above OCT images?

Upon further questioning including review of systems, it was discovered that the patient owns a cat and has been scratched twice in the last 6 months. Lab work serology demonstrated very high titers of Bartonella IgG (<1:256). Testing for toxoplasma gondii IgM, RPR, FTA-ABS and quantiferon gold was negative.

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

Question 3: Which of the following is a potential complication of infectious neuroretinitis?

References:

  1. Fatteh, N., Feldman, B., Shah, V., Vaphiades, M., Bhat, P. and Lim, J., 2022. Neuroretinitis - EyeWiki. [online] Eyewiki.aao.org. Available at: <https://eyewiki.aao.org/Neuroretinitis> [Accessed 25 May 2022].

  2. Michel Z, Redd T, Bhavsar KV. Multimodal imaging of two unconventional cases of Bartonella Neuroretinitis. Retinal Cases and Brief Reports 2022;16:40-43.

  3. Margolin E. (2019). The swollen optic nerve: an approach to diagnosis and management. Practical neurology, 19(4), 302–309. https://doi.org/10.1136/practneurol-2018-002057

  4. Habot-Wilner, Z., Zur, D., Goldstein, M., Goldenberg, D., Shulman, S., Kesler, A., Giladi, M., & Neudorfer, M. (2011). Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis. Eye (London, England), 25(8), 1064–1068. https://doi.org/10.1038/eye.2011.125

  5. Holdeman NR, Ma L, Tang RA (2017) Cat Scratch Neuroretinitis. Int J Ophthalmol Clin Res 4:071. doi.org/10.23937/2378-346X/1410071

  6. Khairallah, M., Khochtali, S. Choroidal neovascularization complicating optic disc drusen, mistaken for Bartonella neuroretinitis. Int Ophthalmol 37, 1083–1084 (2017). https://doi.org/10.1007/s10792-016-0363-8

 

Learning Objectives:

  1. Understand the clinical and laboratory findings of infectious neuroretinitis

  2. Differentiate neuroretinitis from other conditions with similar presentations

  3. Understand the approach to asymptomatic unilateral disc edema