Triple Take - Video

A 42 year-old male noticed difficulty reading labels while stocking shelves at work. Over the next three weeks, he developed a dark "cloud" in his central vision in the left eye, and then the right eye. He did not have associated pain. When evaluated by the retina service, his visual acuities were 20/100 OD and 20/1250 OS without a relative afferent pupillary defect. Goldmann perimetry showed central scotomas OU. His anterior segment was unremarkable. Dilated fundus examination showed subtle telangiectatic vessels on the optic nerve head and in the macula OU. Optical coherence tomography (OCT) showed diffuse inner retinal thinning with focal irregularities in the outer plexiform layer in the macula OU, as well as ganglion cell layer thinning OU. He was evaluated; in neuro-ophthalmology for possible Leber's hereditary optic neuropathy. Repeat visual field, dilated fundus examination, and OCT findings were unchanged from previously. MRI brain and orbits with and without contrast showed subtle bilateral optic nerve enhancement. He was thought to have bilateral optic neuritis. He was admitted for further work-up and management. CSF evaluation showed a minimally elevated protein concentration of 48 mg/dL, with normal constituents otherwise. CSF cytology was negative. NMO antibodies were not detected and a paraneoplastic panel was negative. Further diagnostic testing was performed.KBDparaneoplasticdisease; retinaldystroph