CASE
A 36-year-old US Army helicopter pilot and National Guard captain presented to the aviation clinic in Basra, Iraq, with complaints of a "floater" in his right eye. He described seeing "a crescent-shaped black spot" and a progressively worsening loss of peripheral vision that had been present for the past day. The patient denied any eye drainage, foreign body sensation, tearing, eye pain, headaches, flashes of light, scotoma, or diplopia. He had no history of trauma, straining, or infections and did not wear glasses.
History The patient's medications included atorvastatin (Lipitor) for hyperlipidemia. He denied alcohol use but admitted to occasionally smoking cigars. Results of his annual flight physicals, which included visual examinations and stereopsis testing, were normal. He denied any contact with animals.
Examination The patient did not appear to be in acute distress and was not toxic-appearing. Vital signs were as follows: temperature, 97.8˚F; pulse, 82 beats per minute; and BP, 138/75 mm Hg. A head, eyes, ears, nose, and throat (HEENT) examination was performed. Visual acuity was 20/20 in both eyes. His lids were normal, no photophobia was present, and his pupils were equal, round, and reactive to light. He had full extraocular movements and normal sclera, conjunctiva, and cornea. Anterior chambers appeared clear, and the uveal tract and lens appeared normal. He had a normal physiologic cup, no blurred margins, no papilledema, and no retinal hemorrhage. A hypopigmented, creamy, white exudative lesion extended along the superotemporal region of the right retina. Tympanic membranes, nares, and throat were clear, and his mucous membranes were moist. No lymphadenopathy was noted.
The patient was seen by a military optometrist and then an ophthalmologist in Kuwait, who both diagnosed a visual field defect caused by constriction noted in the inferior nasal aspect of the affected eye. He was then transported to Germany, where a retinal specialist saw him.
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