A 70-year-old black female with a recent history of multiple myeloma undergoing chemotherapy, presents with a 3-day history of intermittent, painless vision loss. The episodes of decreased vision last minutes to hours and are occurring in either eye, but more in the right than left. This morning, she awoke with a complete loss of vision in the right eye that is not resolving.
This patient’s multiple myeloma was diagnosed a few months prior during a workup for upper GI bleed. Treatment for the multiple myeloma has included radiation to a plasmacytoma identified in the left iliac bone and VRd regiment chemotherapy (Velcade, Revlimid, dexamethasone) for the past 3 months. She also has a history of hypertension and deep vein thrombosis (DVT) but is not on anticoagulation due to recent GI bleed.
Examination reveals NLP vision right eye and 20/100 (6/30) left eye. The right pupil is poorly reactive and an rAPD is present. Intraocular pressures, motility, external and anterior segment examinations are all normal with the exception of mild nuclear sclerotic cataracts. The patient is unable to perform visual field examination by confrontation with the right eye but appears to have a superior hemifield defect in the left. Posterior segment examination is shown in the photos below.
Case contributed by: Libing Kathy Dong, MD. Indiana University School of Medicine.