A 33-year-old male teacher presented with a one-month history of blurred vision in both eyes. On examination, he had reduced visual acuity that improved slightly with pinhole correction, abnormal color vision, sluggish pupils with no light reaction difference, and disc edema. He reported a history of heavy alcohol use. A differential diagnosis of acute demyelinating optic neuritis was made given the acute onset, bilateral involvement, and disc edema. He was started on IV steroids and oral steroids to treat optic neuritis and referred to psychiatry for alcohol withdrawal syndrome.

1. Clinical case presentation
Dr. Samten Dorji

2. Chief complaint
• 33 year old male presented to our OPD
with blurring of vision for one month
duration.

3. Personal details
He is from Sephu,Wangdue currently
working as teacher in Langthel,Trongsa.he
is married and has two children.

4. History of present illness
• A month back he had an acute onset of
blurring of vision in both eyes and he could
see movement of letters in his computer
desktop. There was no associated ocular
pain.
• During the month there was no worsening
progression of his vision or improvement but
it stayed the same.
• Patient complains of increase in contrast of
colors

5. Negative findings in history
• No focal neurological weakness
• No history of viral flu prior to that condition
• No pets in house

6. History cont.
• Past ocular history/ocular
medications/systemic
medications/comorbidities/allergies/family
history
• Patient drinks alcohol daily two bottles of
beer and has history of alcohol misuse for
9 years and has history of smoking filtered
cigarettes half packet per day for 9 years.

7. Examination
Right eye Left eye
Visual acuity FC 1m FC 1m
With pinhole FC 1m FC 1m
Color vision Can read plate 1
Cannot read
5,6,9,10,12,13,14,1,7,26,2
5,27,30,32,33
Can read plate 1
Cannot read
5,6,9,10,12,13,14,1,7,2
6,25,27,30,32,33
Extraocular movements Normal Normal
Lids and adnexa Lower lid epiblepharon Lower lid epiblepharon
Conjunctiva and sclera normal normal
Cornea clear clear
Anterior chamber Normal depth and quiet Normal depth and quiet
Iris and lens Normal Normal

8. Examination
Pupil Round regular and
sluggish reflex
No RAPD
Round regular and
sluggish reflex
No RAPD
IOP by Icare tonometer 13 mmhg 15 mmhg

9. Fundus examination
Disc oval hyperemic and blurry margin
Cup disc ratio 0.2 : 1: 0.2
Foveal reflex present
Vessels look normal
Periphery normal

10. Systemic examination
• General appearance: mild facial puffiness
and tremor of hands
• Weight=49 Kg
• CVS: PR=100bpm , BP= 120/70, heart
sounds normal
• RS: RR=20/min chest clear
• Abdomen: unremarkable
• Neurological system: unremarkable

11. Case summary
• 33 year old male, a known alcohol misuser,
had acute onset of blurring of vision one
month back with no progression. On eye
examination he had visual acuity of FC1m
with pinhole correction in both eyes with
bilateral APD with disc edema on fundus
examination. He has bilateral lower lid
epiblepharon. On systemic examination he
had signs suggestive of alcohol withdrawal
syndrome.

12. Problems
1. Reduction of vision with APD and disc
oedema
2. Alcohol withdrawal syndrome
3. Bilateral lower lid epiblepharon

13. Differential diagnosis
1. Acute demyelinating optic neuritis
Supporting points
• Age=33 years
• Acute onset of blurring of vision
• Impaired contrast sensitivity and
color vision
• APD in both pupils
• Disc oedema on fundus examination
Non- supporting points
• No ocular pain or with ocular
movement also
• No worsening or improvement
over the period of one month
• Both eyes less common

14. Differential diagnosis
2. Nutritional optic neuropathy
Supporting points
• Has a history of alcohol
misuse
• Symmetrical bilateral visual
impairment
• Color vision impairment
• Disc oedema
Non-supporting points
• Acute onset of disease

15. Differential diagnosis
3. Neuroretinitis
Supporting points
• Painless acute loss of vision
• Disc oedema
Non-supporting points
• Usually unilateral
• No history of pets in house
• No macular involvement

16. Differential diagnosis
4. Anterior ischemic optic neuropathy
Supporting points
• Sudden onset of loss of vision
• Disc oedema
Non-supporting points
• Affects >50 years
• Usually unilateral

17. Differential diagnosis
5.Parainfectious optic neuritis
6. Infectious optic neuritis
7.Non-infectious optic neuritis

18. Investigation

20. Management
Managed as acute demyelinating optic neuritis
• IV methyl prednisolone 500mg 12 hourly for 3
days followed by 1mg/kg(50mg) OD for 11
days
• Tablet ranitidine 150mg bd
• Artificial tears eye drops
• Referral to psychiatry for alcohol withdrawal
syndrome
• Vitamins

21. Subject review