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 45-year-old woman suffering from intraocular hemorrhage associated with chronic myeloid leukemia complicated by subdural hematoma was referred to our institution. Chronic myeloid leukemia had been diagnosed 10 years earlier and the patient’s comorbidities were treated arterial hypertension, hepatitis B virus positivity, and orally treated type 2 diabetes mellitus diagnosed 3 years earlier. At presentation, she was in blast crisis for the second time and the disease was rapidly progressing. She was hospitalized in the Hematology-Oncology Department, University of Turin, with a very low platelet count (8,000/mm3) and red cell count (2,000 mm3), asthenia, fever, and occipital headache radiating to the anterior parts. A severe subdural hematoma was discovered, with ventricular dilatation and signs of high intracranial pressure. She was treated with repeated platelet transfusions and conservative medical therapy. The patient’s condition improved slowly, with progressive reabsorption of the hematoma and normalization of ventricular morphology on brain computed tomography scan.\nWe followed up this patient for a year by assessment of visual acuity, fundus examination, color retinography, and A-scan and B-scan ultrasonography. The patient complained of visual impairment in the left eye since the onset of her neurological symptoms, and was referred to our clinic. At presentation, her best corrected visual acuity on the right was 20/63 and on the left was 20/320. Retinal examination of the right eye revealed blurring of the optic margins surrounded by retinal and preretinal hemorrhages, preretinal fibrosis starting from the optic disc and extending along the vascular arcades, and perivascular retinal infiltrates (). Massive fibrosis with hard exudates and severe preretinal hemorrhage were observed in the left eye at the posterior pole (). The optic disc was surrounded by retinal and preretinal hemorrhages. Roth spots and many circular and preretinal hemorrhages were noted at the retinal periphery (). The other ocular structures were within normal limits. Ocular tension was good (right, 20 mmHg; left, 17 mmHg).\nA-scan and B-scan ultrasonography showed similar clinical features in both eyes, ie, an anechogenic vitreous cavity, a small increase in the thickness of the chorioretinal complex, and some minute retinal lines with higher reflectivity, likely representing hemorrhages. The patient was monitored for 12 months, with no changes in her clinical and functional characteristics.