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27-year-old Caucasian female

painful monocular vision loss

last two days - acute ( allergic , trauma )

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A 27-year-old Caucasian female

painful monocular vision loss

last two days

FURTHER QUESTIONING

SITE - exact location? ( right or left )

ONSET - first notice vision loss

CHARACTERISTIC -stabbing pain

RADIATES - to anywhere

ASSOCIATED SYMPTOMS - any other symptom ,diabetic? , HTN , retinal detachment ( orang rabun tinggi can lead to vision loss)

SEVERITY - 1 to 10

PMH - medication?

FAMILY HISTORY - genetic ? , multiple sclerosis ( autoimmune ds where immune system attack myelin sheath , Caucasian ) , ada family yang rabun ?

SOCIAL HISTORY - alcohol consumption , occupation

TRAVEL HISTORY - ( infection , dengue , gum bleeding )

DIFFERENTIAL DIAGNOSIS

infection

trauma

cataract

multiple sclerosis

sinusitis

glaucoma

rabun

Diabetic neuropathy

medication

optic neuritis

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paraesthesia - pin and needle

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Initially she developed discomfort in the left eye which

became worse with

eye movements, followed by

progressive blurring of left eye vision; in particular,

coloured objects appeared pale or washed out compared with

their appearance through her right e

ye. There were no right eyesymptoms.

Past medical history

There was no previous ocular history. While giving a detailed history, she

recalled fleeting episodes of limb paraesthesia several times in the past

year lasting minutes, with no other history of transient neurological

symptoms. Past history of asthma but took no regular medications.

Medication history

The patient was not on prescription or OTC medication.

No history of head/eye trauma or surgical procedures

Family history

She had a cousin with multiple sclerosis (MS) and she was very

concerned about her own risk of developing the condition.

Social history

There was no history of alcohol abuse or illicit drug use

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Initially she developed discomfort in the left eye which - effect optic nerve before optic chiasm

became worse with

eye movements, followed by

progressive blurring of left eye vision; in particular,

coloured objects appeared pale or washed out compared with

their appearance through her right e

ye. There were no right eyesymptoms.

Past medical history

There was no previous ocular history. - first time

While giving a detailed history, she

recalled fleeting episodes of limb

paraesthesia several times in the past

year lasting minutes, with no other

history of transient neurological -

history of nerve

Past history of asthma but took no regular medications.

Medication history .The patient was not on prescription or OTC medication - might get Multiple sclerosis

No history of head/eye trauma or surgical procedures

Family history

She had a cousin with multiple sclerosis (MS) and she was very

concerned about her own risk of developing the condition.

Social history

There was no history of alcohol abuse or illicit drug use

DIFFERENTIAL DIAGNOSIS

infection

trauma

cataract

multiple sclerosis

sinusitis

glaucoma

rabun

Diabetic neuropathy

medication

optic neuritis

FURTHER INVESTIGATION

BReHeT ( BP , respiratory rate , HR , temperature )

Temperature high , WBC high , ESR ( inflammation )

pain , heat , redness , loss of fx , swelling ( sign of acute inflammation )

Eye movement test ( ishihara test )

Visual acuity test ( snellen test )

RAPD

Weber test ( to check for photophobia and neck stiffness )

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left eye red desaturation - nampak merah pudar

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1. Vital signs were normal - no fever, no hypertension, no hypotension

2. Visual acuity was 20/20 on the right eye and 20/40 on the left.

nearsightedness (myopia) on the left eye

3. Visual fields were full to confrontation

normal peripheral vision and central vision

4. left eye red desaturation and abnormal colour vision on Ishihara plate testing

abnormal colour vision - cone photoreceptor damage

5. left relative afferent pupillary defect was noted

optic nerve damage

6. On ophthalmoscopy, the cornea, anterior chamber, lens and vitreous humour appeared normal in both eyes, as did both optic discs. There were no haemorrhages or other abnormal retinal findings

7. Eye movements were normal, but she found looking to the extremes of gaze painful in the left eye

8. No other abnormal neurological findings were detected.

9. The remainder of the cranial nerve examination was normal. Strength, coordination, and sensation were normal, as was a gait examination.

cerebellum normal, other nerve normal

10. systemic examination was unremarkable

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DIFFERENTIAL DIAGNOSIS

infection

trauma

cataract

multiple sclerosis

sinusitis

glaucoma

rabun

Diabetic neuropathy

medication

optic neuritis

MOST LIKELY: optic neuritis secondary to multiple sclerosis

triad:

cranial nerve signs - nystagmus

motor and sensory impairment - paresthesia

unilateral visual impairment

DR haplotype at 6 chromosome

environmental factor: away from equator, low vit D, low sunlight exposure

BBB dysfx - cover rosak

1. central nervous system - UMN sxs

2. disseminating in time - on off

3. disseminating in place - cerebellum, cerebrum, brainstem, spine (tempat lain lain)

Further ix

FBC - normal, MCH, MCV, MCHC, hematocrit, platelet, WBC

MRI of brain - white matter plaque

Serology test - Ig G level increase

CSF

OPTICAL COHERENCE TOMOGRAPHY

CRP

BLOOD GLUCOSE