A 62-year-old Caucasian man presented to the eye department with blurred vision in his left eye, which he had noticed 5 days previously.
There was no history of headache, eye pain or diplopia and no other new neurological symptoms.
There was a complicated past medical history. He had had mastoid surgery many years before and was deaf in the left ear. Eleven years previously he had developed staphylococcal septicaemia and meningitis complicated by the development of extradural infection involving the caudal equina. His recovery was incomplete and resulted in weakness of both legs and limited bladder and bowel control.
Current medication was omeprazole and quinine for cramps. He was an ex-smoker for the last 12 years and did not drink alcohol. There was no family history of eye diseases.
On examination the patient appeared generally well. He was apyrexial and normotensive. Visual acuities with correction were 6/12 right and 6/60 left. Pupils were equal but there was a marked left relative afferent pupil defect. Eye movements were full with no ptosis.
Colour vision testing by Ishihara method showed impairment mild on the right and severe on the left. Automated perimetry showed a superior nasal arcuate field loss on the right and gross generalised field loss on the left ().
Fundus examination revealed bilateral disc swelling with absent spontaneous venous pulsation (). The disc swelling was more marked on the left side. In both eyes the rest of the retinal examination was normal.
Optic disc appearances at presentation.
Temporal arteries were palpable and non-tender. Chest and abdominal examination was unremarkable. General neurological examination revealed no new neurological signs just the longstanding mild weakness of both legs and left-sided deafness.
The patient was admitted under the physicians and vision progressively deteriorated for the first week to only hand movement vision on the left and maintained acuity but loss of upper hemi field on the right.