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Case 28


Patient Presentation: A 54-year-old man presented to a neuro-ophthalmology clinic following a referral for optic nerve swelling. The patient’s only initial symptoms was 2-3 weeks of colourful flickering lights on his left visual field, which was worse in the mornings than evenings. He initially denied vision loss, eye pain, headaches or meningeal symptoms. He denied recent trauma or infection. He denied drug use or risky sexual behaviour. His last eye exam was 6 months prior to presentation, and his vision and eye exam were normal. His past medical history was significant for T2DM and hypertension, of which he was appropriately treated with medications.

On examination, his best corrected distance visual acuity was 20/40 OD and 20/200 OS. Intraocular pressure was normal and there was no RAPD. Anterior segment examination was normal. Fundus photos and fundus autofluorescence images were taken and are shown below:


Question 1: What are the main findings seen in the fundus photo and fundus autofluorescence images above?

Formal 24-2 Humphrey visual fields were conducted, which demonstrated dense generalized depression in the left eye and an inferior altitudinal defect in the right eye (shown below):


At this point, the patient was further questioned about his visual complaint. He did note visual decline over the last 6 months in the left eye. He was further probed on a review of systems, and he did disclose risky sexual behaviours including unprotected sexual intercourse with multiple male partners a week.

OCT ONH/RNFL and OCT macula images were taken at this time and are shown below:


Question 2: What is the main finding in the OCT macula images above?

Question 3: Based on the patient presentation, fundus findings and OCT imaging, what is the most likely diagnosis?

The patient underwent syphilis serology screening. He was reactive for syphilis serology, with a RPR quant level of 1:1024.

Question 4: What is the treatment of acute syphilitic placoid chorioretinitis?

Learning Objectives:

  1. Learn the hallmark OCT features of acute syphilitic placoid chorioretinitis

  2. Understand that ocular syphilis can mimic a number of ocular infectious and inflammatory conditions, and targeted questioning of risky behaviours should be undertaken

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