Woman experiences decreased vision with normal fundus exam

A 26-year-old female nursing school graduate was referred to the New England Eye Center for decreased vision in both eyes with a normal fundus exam. One month before referral, she noted gradually worsening vision more significant in the right eye than the left. Other than a vague history of back pain and numbness in her right toe, she had no other significant medical or family history. A recent MRI of the brain showed no abnormality.The patient’s best corrected visual acuity was 20/200 in the right eye and 20/30 in the left. Pupillary exam showed a trace relative afferent defect on the right. IOPs and anterior segment exam were unremarkable. Funduscopic exam showed peripapillary telangiectasias (Figures 1 and 2). OCT of the ganglion cell layer showed bilateral thinning (Figure 3), while OCT of the retinal nerve fiber layer showed overall mild thickening with mild temporal thinning (Figure 4). After examination, we requested her visual fields from the referring ophthalmologist, which showed bilateral cecocentral scotomas (Figure 5).