Neuroretinitis with Branch Retinal Artery Occlusion in a 15-Year-Old Female
A 15-year-old female presented with a 4-week history of progressive, painless loss of vision and inferior visual field defect in the left eye (OS). Her history was negative for red eye and discharge, but she reported having a fever and sore throat without other constitutional symptoms. Physical exam did not demonstrate other neurological disturbances or lymphadenopathy. The patient was never sexually active and her past medical history was insignificant. She reported having traveled to Vietnam for 6 weeks within the past year. The patient had contact with a friend's cat, but denied being scratched. Blood pressure at presentation was 110/65 mm Hg with no history of systemic hypertension. The best-corrected visual acuity was 20/20 in the right eye (OD) and 20/40 OS. Pupils were round and reactive with a moderate left afferent pupillary defect. Color vision was also impaired OS, and a confrontation visual field test revealed an inferior field defect OS.\nThe anterior chamber and vitreous showed trace cells, and her intraocular pressure was 14 mm Hg in both eyes at presentation. The posterior segment exam was normal OD, but significant disc and retinal edema, peripapillary serous retinal detachment and vascular congestion were observed OS. A characteristic partial macular star sparing the area temporal to the fovea was also observed OS (fig. ). Subfoveal fluid was present and confirmed by optical coherence tomography. A branch of the superior-temporal retinal artery was occluded, but the arteriole supplying the superior part of the macula remained patent (fig. , fig. ). Venous tortuosity and peripapillary telangiectasia were present, but there was no sign of concomitant vein occlusion (fig. , fig. ). A clinical diagnosis of B. henselae vaso-occlusive neuroretinitis was made, and doxycycline 100 mg p.o. b.i.d. was prescribed. The B. henselae IgG titer was elevated (1:128). Lyme and syphilis serologies and a purified protein derivative skin test were negative. While not routine in cases with a high clinical suspicion of B. henselae infection, an MRI of the brain and orbits as well as a chest X-ray were performed to exclude other infectious etiologies.\nAfter 2 months of doxycycline therapy, the disc and retinal edema had improved significantly and most retinal vessels returned to normal caliber (fig. ). Visual acuity improved to 20/20 with improved color vision, but the left afferent pupillary defect was still present. Central visual field defects improved with the resolution of macular edema, but the branch retinal artery occlusion resulted in inner retinal infarct with a persistent inferior arcuate scotoma (fig. ).