Bilateral Idiopathic Neuroretinitis

Abstract

Background/objectives: Neuroretinitis (NR) is a rare inflammatory condition characterized by sudden vision loss, optic disc edema and macular star appearance predominantly affecting individuals in their third and fourth decades of life.

Methods: This paper describes the case of 33-year-old Caucasian man with no significant medical history complaining of decreased vision for about a week.

Results: The ophthalmological exam revealed best-corrected visual acuity (BCVA) for the right eye (RE) of 0.8 (decimal notation) and of 0.9 for the left eye (LE). Intraocular pressure (IOP) was 20 mmHg in RE and 18 mmHg in LE. Slit-lamp examination of both eyes (OU) showed no evidence of intraocular inflammation in the anterior chamber or vitreous cavity. Examination of the posterior pole of the right eye showed bilateral papilledema with an incomplete macular fan pattern.

Conclusions: Despite extensive laboratory tests, including serologic and imaging investigations, a definitive etiology remained unclear. It is very important to differentiate NR from other optic nerve disorders, requiring careful clinical evaluation and observation of the evolution of symptoms.

Keywords: macular fan; neuroretinitis; optic disc edema.

Figure 1

Retinophotography of both eyes (OU) in a 33-year-old Caucasian man with no significant medical history presenting to our service with decreased visual acuity for about a week. There were no other constitutional symptoms, history of tuberculosis or contact with dogs, cats or other pets. The ophthalmological examination revealed best-corrected visual acuity (BCVA) in the right eye (RE) of 0.8 and 0.9 for the left eye (LE). Intraocular pressure (IOP) was 20 mmHg in RE and 18 mmHg in LE. Slit-lamp examination (OU) showed no evidence of intraocular inflammation in the anterior chamber or vitreous cavity. Color vision was impaired in the right eye more than that in the left eye. There was no pain on ocular movement. Examination of the posterior pole (RE) shows an elevated optic nerve papilla with blurred contour, a few peripapillary microhemorrhages (white arrow) and a cotton wool spot, as well as hard exudates, characteristically arranged in the pattern of an incomplete macular fan. In the LE we noticed a slightly elevated optic nerve papilla with blurred contour, a few exudates in the peripapillary region (black arrow) and some perivascular microhemorrhages in the infero-temporal sector.

Figure 2

Optical coherence tomography (OCT) of the OU at first presentation showed bilateral papilledema with peripapillary subretinal fluid presence. In the RE, we noticed the presence of intraretinal and subretinal fluid (white arrow) extending from the optic disc along with neurosensory macular detachment and hard exudates in the inner layers of the retina (red arrow). Central macular thickness was 429 μm in the right eye and 317 μm in the left eye.

Figure 3

Visual field of both eyes performed at first presentation. A decrease in retinal sensitivity (OU) was noticed. In the RE, the major defect is a superior macular arcuate scotoma and a large blind spot (RE). The other eye (LE) shows similar arcuate defects but is much less dense.

Figure 4

Visual field of both eyes performed after one month follow-up. The patient’s clinical features improved after the treatment. BCVA was 0.9 in RE and 1 in LE. Intraocular pressure (IOP) was 15 mmHg in RE and 16 mmHg in LE.

Figure 5

Retinophotography of both eyes (OU) at six weeks after the first presentation. We noticed that the optic nerve swelling decreased in both eyes and visual acuity was back to normal but exudates persisted in the peripapillary region along with a few peripapillary microhemorrhages (RE).