A 50-year-old African American female presented with a three-week history of intractable headache, confusion, vertical binocular diplopia, photophobia, and difficulty with balance. Examination revealed best corrected visual acuities of 20/25 in the right eye (OD) and 20/20 in the left eye (OS) with intraocular pressures (IOP) of 14 mmHg in both eyes (OU). No afferent pupillary defect was noted, extraocular motility (EOM) was full OU, and confrontational visual fields were full OU. Anterior segment examination in both eyes was unremarkable. Funduscopic examination of both eyes revealed grade-four optic disc edema, blurring of optic disc margin, and obscuration of vasculature of the optic nerve. Preretinal and intraretinal hemorrhages were present in both eyes, largely concentrated in the peripapillary retina, but extending to the mid-peripheral retina (Figures and ). Optic nerve swelling was confirmed on optical coherence tomography (OCT) of the retinal nerve fiber layer (Figures and ). Fluorescein angiography revealed hyperfluorescence of the optic disc OU (Figures and ).\nComputed tomography of the head, magnetic resonance imaging of the brain, and magnetic resonance venography of the brain were unremarkable and had no evidence of intracranial mass, hemorrhage, or ischemia. Cerebrospinal fluid (CSF) analysis revealed an opening pressure of 30 cm H2O, 77 white blood cells/mm3 with 94% lymphocytes, 93 mg/dL protein, and 73 mg/dL glucose. Bacterial and fungal cultures of the CSF were negative. CSF studies for Lyme, syphilis, herpes simplex virus, and West Nile virus were unremarkable. A limited panel consisting of laboratory studies for enterovirus, syphilis, ANA, and p-ANCA was negative. A respiratory viral panel for adenovirus, cytomegalovirus, influenza, parainfluenza, rhinovirus, and respiratory syncytial virus was negative on Polymerase Chain Reaction testing. Based on the patient's presentation and cerebrospinal fluid findings, she was diagnosed with viral meningoencephalitis. She was monitored as an inpatient with conservative management. During the hospital course, the patient noted improvement in her double vision and headaches. A repeated lumbar puncture 5 days later revealed opening pressure of 4 cm H2O, 38 white blood cells/mm3, 75 mg/dL protein, and 57 mg/dL glucose. The patient was subsequently discharged from the hospital.\nFollow-up examinations with serial OCT of the optic nerve showed continued progressive improvement in disc edema (Figures –) along with complete resolution of papilledema and peripapillary hemorrhages (Figures –). Mild residual pallor of both optic nerves was observed at the end of one year. OCT revealed borderline temporal thinning of the right optic nerve. The left optic nerve had borderline temporal thinning, borderline superotemporal thinning, and inferotemporal thinning. The findings of persistent disc pallor and inferotemporal nerve fiber layer thinning on OCT were consistent with the persistent visual field deficit documented on Humphrey visual fields (Figures –).
A 33-year-old man with no past medical history presented with a 3-day history of blurred vision and intense photophobia in the LE 3 weeks after the onset of mild chikenpox. On examination, BCVA was 20/20 in the RE and 20/30 in the LE. Slit-lamp examination of the LE showed perilimbal injection, fine keratic precipitates, and 2+ cells with 1+ flare in the anterior chamber. Intraocular pressure was 16 mmHg. There was no vitritis, and dilated fundus findings were normal. Examination results of the RE were normal. A diagnosis of unilateral acute non-granulomatous anterior uveitis secondary to varicella was made. The patient was treated by topical dexamethasone six times a day and cycloplegic agent twice daily. The uveitis resolved within 2 weeks, and visual acuity improved to 20/20 in the LE. No recurrence of uveitis was observed over a follow-up of 12 months.