ABSTRACT[f1] diabetes mellitus was administered at the Ophthalmology

ABSTRACTf1 

            Neuroretinitis is an inflammation of
optic nerve and retina. It is often confused with papillitis, papilledema,
central retinal vein occlusion (CRVO), and anterior ischemic optic neuropathy
(AION). Although the etiology is still not well-understood, studies have shown
that it is mostly caused by cat-scratch fever, syphilis, Lyme disease, mumps,
and leptospirosis. Besides that, some studies showed that it might also be
idiopathic. This paper presents a case of neuroretinitis due to obscure cause.

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BACKGROUND   

            Neuroretinitis is a type of optic
neuropathy characterised by an acute unilateral visual loss in the setting of
optic disc swelling accompanied by hard exudates arrange in a star shaped
around the fovea (Kaliaperumal, & Narayan, 2013). Funduscopically, it
shares a few common features with papillitis, papilledema, CRVO, and AION. On
the other hand, there are certain features such as etiology and pathogenesis
that differs neuroretinitis with other form of optic neuropathy. f2 Sixty
percent of cases are resulted from cat-scratch fever, 25% are idiopathic, while
the rest of the cases are caused by syphilis, Lyme disease, mumps, and
leptospirosis (Bowling, 2016).

CASE PRESENTATION

            A 62-year-old lady, underlying
diabetes mellitus was administered at the Ophthalmology Clinic of Hospital
Tengku Ampuan Afzan (HTAA), Kuantan on 12th July 2017. She has
undergone cataract surgery for both eye. A week after her left eye (LE)
surgery, she complained a painless blurring of vision on her right eye (RE).
However, there was no systemic complaint such as fever, joint pain, and others.

 

 

INVESTIGATION

            Several tests were carried out in
order to diagnose her condition. Her LE’s ocular findings are normal. While for
her right eye (RE), the unaided visual acuity is 6/36 (with pinhole: 6/18). The
other ocular structure (RE) such as conjunctiva, cornea, and posterior chamber
intraocular lens implantation (PCIOL) appreared to be normal. Conversely, slit
lamp examination revealed an optic disc swelling and hyperemic, splinter
hemorrhage surrounding the optic disc with slight tortuous vessel, macula edema
with star-shaped figure of hard exudate. Other vital test such as pupillary
response discloses a positive relative afferent pupillary defect (RAPD) and Humphrey
visual field test revealed that she has centrocaecal scotoma. Thus, the doctor
diagnosed her with RE leber’s idiopathic stellate neuroretinitis based on the
appearance of the fundus and the symptoms reported. The diagnosis would be
appropriate because even though the patient’s neighbour has 13 cats, the
patient has no history of cat scratch or any contacts with the cats. Moreover,
the other possible causes for neuroretinitis such as syphilis, Lyme disease,
mumps, and leptospirosis exposed a negative serological test result.

TREATMENT AND FOLLOW-UP

            In order to reduce the inflammation, the warded patient was administered
with intravenous methylprednisolone (250 mg) for six days. The RE vision
improved to 6/12 after a period of 4 days. After 6 days in hospital, doctor has
released the patient with an oral prednisolone. Four months later, with the
deep exudates remained but otherwise the fundus became normal with the return
of visual acuity to 6/9. No neurological symptoms appeared at any time. Follow-up
to monitor its progression has been set for two-months intervals.

DISCUSSION

            Neuroretinitis potrays with sudden visual loss, swelling of the optic
disc, peripapillary and macular exudates that may occur in a star-shaped
pattern and cells in the vitreous (Narayan, Kaliaperumal, & Srinivasan, 2008). This
disease can affect mostly those in the third and fourth decades of life with no
gender preferences and came with a complaint of painless unilateral visual
impairement (Bowling, 2016). At the early of ocular examination, patient
usually will get visual acuity in the range of 6/6 to light perception and the
most common visual field defect is caecocentral scotoma. Next, most of the
patient would have a positive relative afferent pupillary defect (Narayan, Kaliaperumal, & Srinivasan,
2008).

            The
pathogenesis of neuroretinitis is unknown. It is correlated with direct
involvement of an infectious or inflammation process preceding to the optic
nerve edema, thus causing cellular and fluid exudation from the inflamed area
of peripapillary retina (Narayan, Kaliaperumal, & Srinivasan,
2008). The star pattern of exudates (Picture 1) showed a loose and radial
configuration of the outer plexiform layer in the macula (Purvin &
Kawasaki, 2009).

 f1Macam nak sama dengan https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771962/

 f2Never start a sentence with numbers