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Goldmann visual field test shows inferior nasal quadrantanopsia in the left eye.
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Figure 1: Goldmann visual field test shows inferior nasal quadrantanopsia in the left eye.

Mentions: A 26-year-old healthy woman developed fever and maculopapular rash expanding from the face to the trunk and the four limbs. Subsequently, Koplik spots were present and measles was diagnosed. Three days after the onset of rash, she noticed blurred vision in the left eye. One week later, she visited a neighboring hospital and quadrantanopsia was found in her left eye. She was admitted to our department. Physical examination was normal. A Goldmann visual field test revealed inferior nasal quadrantanopsia without central scotomas in her left eye. The visual field of her right eye was normal (fig. 1). The corrected visual acuity was 20/20 in OD and 20/100 in OS. Pupillary size was 2.0 mm in the right eye and 4.0 mm in the left eye. Light reflexes were slightly sluggish in her left eye. Ophthalmoscopy showed mild pallor of the left optic disc. Neurological examination was normal except for visual dysfunction. Routine laboratory tests, electrocardiogram and chest X-ray were normal. Serum IgG titers of anti-measles antibodies were increased to 1:94.8 in an enzyme immunoassay (normal <1:2.0). Cerebrospinal fluid (CSF) examination disclosed a cell count of 1 mononuclear cell/mm3, protein levels of 38 mg/dl and cytology of class II. Myelin basic protein and oligoclonal IgG bands were negative. CSF IgG titers of anti-measles antibodies were elevated to 1:0.64 (normal <1:0.20). Serum anti-aquaporin 4 antibodies were not detected. In electrophysiological studies, sensory and auditory evoked potential tests were normal. An electroencephalogram was normal. Central critical flicker fusion frequency (CFF) showed 40.7 Hz in her right eye and 10.1 Hz in her left eye (normal =29.0). P100 latencies of visual evoked potentials disclosed 90.6 ms on the right side and 133 ms on the left side. Brain and spinal cord MRI revealed no pathognomonic lesions. Orbital MRI displayed abnormal enhancement in the left optic nerve (fig. 2). Our patient had seropositive and CSF-positive anti-measles antibodies, neuroophthalmic findings and abnormal enhancement of the left optic disc. These findings supported the diagnosis of unilateral measles-associated retrobulbar ON. Methylprednisolone pulse therapy (1,000 mg/day for 3 days, i.v.) and subsequent administration of prednisolone (1 mg/kg per day, p.o.) were performed. Prednisolone was tapered off within 1 month. After steroid treatment, left quadrantanopsia was improved and left visual acuity also normalized to 20/20. CFF was increased to 36.4 Hz in her left eye.

Unilateral Measles-Associated Retrobulbar Optic Neuritis without Encephalitis: A Case Report and Literature Review

Hirayama T, Ikeda K, Hidaka T, Nagata R, Yoshii Y, Kawabe K, Iwasaki Y - Case Rep Neurol (2010)

Bottom Line: Little is known about measles-associated retrobulbar ON.Left measles-associated ON was diagnosed.Thus, physicians should pay more attention to variable patterns of measles-associated ON.

Affiliation: Department of Neurology, Toho University Omori Medical Center, Tokyo, Japan.

ABSTRACT
Optic neuritis (ON) is a rare neurological complication of measles infection. Little is known about measles-associated retrobulbar ON. Here, we report a distinct patient with unilateral retrobulbar ON due to measles infection. A 26-year-old woman developed maculopapular rash and Koplik spots. On the following 3 days, she noticed blurred vision in the left eye. A Goldmann visual field test showed inferior nasal quadrantanopsia in the left eye. Visual acuity was 20/20 in OD and 20/100 in OS. Pupillary size was 2.0 mm in the right eye and 4.0 mm in the left eye. Light reflexes were slightly sluggish in the left eye. Ophthalmoscopy showed mild pallor of the left optic disc. Central critical flicker fusion frequency (CFF) was 40.7 Hz in the right eye and 10.1 Hz in the left eye (normal =29.0). Visual evoked potentials showed that P100 latencies were delayed on the left side (133 ms). Brain and spinal cord MRI was normal. Orbital MRI displayed abnormal enhancement in the left optic nerve. Serum and cerebrospinal fluid IgG titers of anti-measles antibodies were increased. Left measles-associated ON was diagnosed. Methylprednisolone pulse therapy followed by oral administration of prednisolone ameliorated visual acuity, visual field and CFF. The neuroophthalmic profile of our patient indicated that measles infection triggered isolated retrobulbar ON, leading to unusual visual deficits. Thus, physicians should pay more attention to variable patterns of measles-associated ON.

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