Rapid vision loss in a 15-year-old boy

Abstract

A 15-year-old boy with a recent diagnosis of T-cell acute lymphoblastic leukaemia (ALL) and a history of factor V Leiden heterozygosity presented with a sudden onset of bilateral vision loss over a 24 h period. 2 weeks prior to presentation he received pegaspargase chemotherapy. During the week preceding admission he had noted mild blurred vision and complained of retro-orbital headaches. Ophthalmic examination revealed visual acuity of 20/800 in the right eye and minimal light perception in the left eye. He had sluggish pupillary reactivity to light with a left relative afferent pupillary defect. Dilated fundoscopic examination demonstrated bilateral florid optic disc swelling with peripapillary and dot-blot haemorrhages in the periphery, and macular oedema of the left eye. Neurological examination demonstrated mild left peripheral seventh nerve palsy.Multiplanar and multisequence MRI of the orbits, face and neck were obtained before and after administration of 20 cc iv contrast (Figures 1-4).