 Hi guys, I'm Pete Hannon, I'm a neurology resident and I was fortunate to do an ophthalmology rotation last month. So I'm going to talk about a 28-year-old woman with nuanced vision loss. Her chief complaint was decreased vision. It was worse than the left eye. She also noted a light that she described in this eye. She's a 28-year-old right-handed Hispanic woman. She has a long-standing history of bad eyesight, which was not significantly improved after a Lasik surgery in 2002. And she feels that her vision has been blurrier than usual for two months after a UTI. Two weeks prior to us seeing her in neurooptoclinic, she was sitting at a computer doing desk work and she noticed a bright light in her left eye. This light was present with her eyes open or closed. She thought her vision got a little bit better initially for about three to four days after this initially happened, but then it worsened. She denies any eye pain, headache, or tinnitus. And it's so bad she no longer feels comfortable driving. She had stopped driving for two weeks prior to us seeing her. She feels her left eye used to be better, but now it's her right eye. So she went to an area vision center. She was 2,400 OD and and OS without correction. She was 2,150 in the right eye and 2,200 with correction, which she felt was worse in her baseline. They did a Humphrey visual field that showed this sort of secocentral scatoma. And they described it as a unilateral optic disc elevation edema on their exam. They did an MRI, interestingly, right off the bat. And this is a fat sat T2, I believe, that shows relatively normal nerves. It was read as a normal exam. So review systems was significant for a 10 pound weight loss over the last five months. She denies any night sweats, fatigue, or musculoskeletal complaints. She's had significant depression and anxiety, which she related to a bad breakup with her ex-husband. She's had persistent dysuria and flank pain and no rashes. Otherwise, a negative review of systems. She's had a longstanding history of recurrent UTI. She says she gets two to three per year. The one two months prior, she felt hadn't been properly treated. She still had flank pain and dysuria. She had this Lasik procedure in 2002 in Mexico City. Her vision never improved. Otherwise, her past medical history is pretty non-contributory. Social history, no tobacco or drug use, very occasional alcohol use. Her husband had multiple partners. He was sleeping around. She travels back and forth from Mexico. She had been there relatively recently. And she has no significant contact with pets, specifically asking about cats. Physical exam, when we saw our visual acuity, again, was 2,400. Pinhole to 2,100 in the right eye, and 2,400 with no change in pinhole on the left eye. She had no relative afferent peupillary defect. And her visual fields, although intact in all four quadrants, she again noted some visual complaints. This is her ampere grids relating back to the secocentral scatoma. Her extraocular motility was full. She had poor color vision in the left eye. Her stereopsis was absent. Her anterior segments were clear and quiet. And her intraocular pressures, it was 13 millimeters of mercury on the left eye. So on fundus exam, her right eye showed these concerning retinal pigment changes. And then on her left eye, we saw this. So for residents and students, what do you see? Anybody? How's it abnormal? So there's some dyscadema. And there's this macular with a star pattern exudate. Angiography showed some leakage of contrast right around the optic nerve. However, the rest of her vasculature seemed mostly intact. And so she had optic dyscadema with macular star, or ODEMS. So the differential neural retinitis is commonly associated with it. But there's also some other conditions like hypertensive retinopathy. Papillodema with usually severely increased intracranial pressure, anterior ischemic optic neuropathy, diabetic papillopathy, vitreous traction, disc and juxtapapillary tumors, and some toxic causes. So neural retinitis is typified by the swelling of the optic nerve along with these exudates in the retinol star pattern. So the reason that we see the exudates in that star pattern is the lipoprotonaceous deposits settle out in Henle's layer, which is deep within the macula. And the nerve fibers run in sort of a radial pattern. So it settles out in that star pattern that we see on a fundoscopic exam. So for neural retinitis, there's numerous infectious etiologies. It's sort of an infectious disease doctor's exciting day at the beach. So there's bacteria, Bartonella, Hensley, or Katscratch disease is one of the most common infectious causes. Rocky Mountain spotted fever, TB, Salmonella. Toxoplasmosis is a protozoa that can cause this. Several spirochetes, significant syphilis, Lyme disease, and leptospirosis. Multiple Vyri, measles, mumps, rubella, the 3Vs, HSV, VZV, and CMV. Hepatitis and coxsac can cause it, as well as dengue fever. Toxicaricanus, anemotode has been associated with it. And several fungi, including histoplasmosis, coxidiomycosis, and actinomycosis. There was a case report where it was associated post vaccination of a rabies vaccine, where a patient got bilateral neural retinitis. But they felt it was due to the vaccine. And several important non-infectious causes, including sarcoid, irritable bowel disease, and periardoritis nodosa. So what about our patient? She denied any specific contact with cats. She was from Mexico and traveled back and forth. Her ex-husband slept around, exposing her to STDs. She had this history of recurrent UTIs and still had urinary symptoms. And this recent 10-pound unintentional weight loss. And as she made sure we knew, she also had no insurance. So it's easy to run a battery of tests in situations like this. We can just open up the order menu and start ordering one after another. She was very concerned about her finances. She had already paid out of pocket for an MRI and was asking us to be a little bit more specific about the test we chose. So our dilemma is what studies did we order? So we decided to go after potentially treatable causes and to look for the most common causes first. So she had this urinary tract infection. We wanted to do a UA in culture that's low-hanging fruit. HIV one-and-two, secondary to a risk for STDs. That would just broaden our differential greatly. RPR for syphilis, Bartonella Hensley for cat scratch disease, ACE levels for sarcoid. We ordered a quantifier in gold versus the standard skin test because she had a history of BCG vaccination. And then a chest x-ray that would help look for both sarcoid and TB. So the results came back. She did have a urinary tract infection, but it was E. coli, pan sensitive. She was negative for HIV one-and-two. Her RPR was negative. Topso was negative. ACE levels were normal. Her Bartonella Hensley antibodies were within normal limits. Her quantifier in gold came back high. So quantifier in TB gold is an indirect test for the mycobacterium tuberculosis complex organisms. And basically, it injects small peptides that are related specifically to these organisms and then quantifies the amount of interfering gamma levels. It's thought to be very accurate, even with prior BCG vaccinations. And it's because the peptides they use are not don't cross-react with the BCV vaccination. And there was a recent system review in the British medical bulletin. They looked back and sort of went through all the studies to see how well these quantifier and test work. They thought the sensitivity range from 64 to 93%, and the specificity range from 89 to 100%. So it's a fairly effective test. So TB neuroretinitis. TB is well-recognized as an ocular pathogen, but it's more typically associated with neuritis when talking about the nerve. And when it's an optic neuritis, it's usually a complication of a systemic infection often associated with meningitis. Specifically for TB neuroretinitis, there's a couple of cases described in association with a large peripapillary caroidal lesion. It's much less common to have it just an isolated case of neuroretinitis. Steschulti and his colleagues in 1999 described a case of a 43-year-old Mexican immigrant who had an isolated neuroretinitis with macular starring in a positive PPD. The setting of otherwise normal studies and exams. So it sounded somewhat similar to our patient. This is their black-and-white version of the fundoscope imaging. There's a clearly edematous disc, but then it's a little bit harder to see the starring. You can see some exudate there on the macula. And on the right is her PPD, which was greater than 15 millimeters. So in this particular patient, treatment with isoniazide and rifampin resulted in prompt resolution of her cordial infiltrates. She also had an exudated retinal detachment that flattened and vision improved. So it was our plan. These aren't our ID doctors, but we decided to talk to ID doctors. Sorry. These are from UCLA. And they felt that we should repeat the TB, the quantifier and gold. And I think the reasoning, looking through the literature, although it's a sensitive and specific test, it does have problems when it's not handled properly and can be less sensitive and specific. So they want it repeated. This patient will also get ophthalmology, neuro-optimology, and neuro-optimology follow-up. I'm not sure why those pictures are flipping. So in conclusion, in the setting of painless vision loss, it's always very important to pay close attention to macular findings. And this is something that I'll take to my neurology colleagues because we're sort of fixated on the nerve. The differential of neuro-retinitis is very broad and can entail extensive workup. Should always consider the cost of studies with or without insurance, but specifically if a patient is uninsured. And then just take a more purposeful course and how to rule out what's going on. And we decided the treatable causes first. In a case study of isolated TB retinitis, treatment of the underlying condition resulted in improvement of revision and ocular findings. With this patient, we're actually having some problem with follow-up and that brings up a whole nother issue. And if this is what's going on and it's similar to the previous case study, she'll get more vision back quickly. Thank you guys very much.