The Clues

• Medical history significant only for depression and migraine headaches
• Examination revealed a single dot hemorrhage between the equator and the ora serrata at 10 o'clock
• No evidence of carotid disease on auscultation

The patient was referred for a routine physical and was scheduled in three months for a dilated fundus exam. Three weeks later she called complaining of flashing, colored lights OD which would come and go and a right-sided headache. Upon reexamination in office . . .

• BCVA: 20/30 OD, 20/20 OS
• No afferent pupillary defect (APD)
• Color vision markedly reduced OD, normal OS
• No pain on eye movement
• Visual field testing revealed an enlarged blind spot
• Slit lamp findings unremarkable OU
• Fundus OS unremarkable; OD as shown below as well as multiple hemorrhages in all quadrants between the equator and the ora serrata

Results from physical were significant only for elevated cholesterol. MRI (not ordered by us!) was essentially normal with no optic nerve inflammation.

Follow-up over the next month included . . .

• A drop in vision to 20/80 OD with a recovery to 20/30+
• Color vision returned to normal
• Visual field defect enlarged to include a partial superior arcuate scotoma
• Mild macular edema developed
• Optic nerve swelling and retinal hemorrhages improved

Patient lost to follow-up.

The Conclusion

Enter the parlor for the diagnosis and discussion of this case.