Case 3: Painless Vision Loss in an Adolescent

Presentation

A 13-year-old boy with attention-deficit/hyperactivity disorder presents with 5 days of painless left eye blurry vision and a central area of vision loss.

Ten days before presentation he had a left-sided temporal headache that was associated with photophobia and lasted for 3 days before spontaneous resolution. Thereafter, he developed blurriness of vision in his left eye that progressively worsened, and he noted a black area in the center of his visual field.

Two months before presentation, the patient had found a tick on his calf shortly after being in a wooded area in western New York. At that time, he developed a raised rash on the nape of his neck but did not have any fevers or neurologic or systemic symptoms. He went to an urgent care clinic, where he was treated presumptively for Lyme disease with 10 days of doxycycline; his rash resolved promptly, and he had no other interim symptoms.

On initial assessment in the emergency department, the patient is afebrile and well-appearing. Both eyes appear normal, with no injection of the conjunctiva or signs of photophobia. On examination of the left eye by an ophthalmologist, his previously normal vision is noted to be limited to counting fingers at ¹/₂ ft distance, and he has a large central scotoma. Dilated fundoscopy reveals 4+ disc edema, with yellow exudates along the temporal disc …