Light at the End of the Tunnel - Slides

A 24-year-old Chinese man presented with 1-year history of progressive blurring of vision of the right eye. He had no significant past ocular nor medical history except moderate myopia and migraine. On ophthalmologic examination, his corrected visual acuity at distance was 20/100 OD and 20/30 OS. Ishihara OD failed test plate, OS 3/14. Ocular examination, including intraocular pressure, was normal, except the finding of bilateral disc pallor with enlarged cup-disc ratio of 0.9 OD and 0.7 OS. Visual field examination showed OD general depression and OS tunnel vision. OCT retinal nerve fiber layer analysis confirmed optic atrophy OU. MRI brain and orbit with contrast did not show any optic nerve abnormalities, but there were abnormal T2 hyperintensities at the genu of corpus callosum and the adjacent white matter, which were commented as highly suggestive of demyelinating disease. Other investigations including C-reactive protein, anti-nuclear antibody, rheumatoid factor, vitamin B12, folate levels were all normal. Neuromyelitis optica antibody was not found. Lumber puncture showed CSF white cell count of 13 (99% lymphocyte), and oligoclonal bands were present. Alpha-fetoprotein (AFP) and beta- human chorionic gonadotropin (b-HCG) levels, in serum and CSF, were normal. Multiple sclerosis was suspected, and intravenous steroid therapy was considered, but withheld since the diagnosis was not certain and there was no definite evidence of acute deterioration. When reviewed 2 months after initial presentation, his visual acuity had dropped to 20/400 OS and 20/100 OS. In view of the rapidly deteriorating visual acuity, the MRI was reviewed. It was felt the nodular ependymal and hypothalamus/ pituitary stalk lesions were atypical for demyelination. A diagnostic procedure was performed.VBintracranialtumor