A 47-year-old African-American male presented to the Wills Eye emergency room for acute, severe, boring right eye pain that had been present for three days. On further questioning, the patient reported poor night vision and occasional flashes and floaters. These symptoms had been slowly progressing for months to years. Review of systems was negative for fevers, cough, sinusitis, neurologic dysfunction, arthralgias, and genital ulcers or pain.
Past ocular history included central serous chorioretinopathy secondary to systemic steroid therapy. Past medical history included: HIV infection with an undetectable viral load and a recent CD4+ count of 450/mL; syphilis that was treated three times previously with intramuscular penicillin with a rapid plasma reagin (RPR) titer of 1:4 three months prior; sarcoidosis; hepatitis B and C infection; and hypertension. Family history was non-contributory. Social history was significant for one-pack-per-day cigarette use and unprotected same-sex intercourse; he denied any drug use. Current medications included ritonavir, rilpivirine, darunavir, dolutegravir and emtricitabine.
Ocular examination demonstrated visual acuity of 20/20 OD and 20/30 OS. Pupils were normal, and intraocular pressures were 15 mmHg OD and 16 mmHg OS. Confrontation visual fields were circumferentially constricted in both eyes. Extraocular motility was full bilaterally. Anterior segment examination revealed focal temporal injection in the right eye that didn’t blanch with phenylephrine and trace nuclear sclerosis cataracts OU.
Dilated fundus examination demonstrated petalloid macular edema in the left eye. The peripheral retina of both eyes showed symmetric, circumferential scalloped areas of depigmentation with scattered areas of pigment clumping (Figures 1 and 2).
Figure 1. Montage fundus photograph of the left eye showing circumferential retinal atrophy extending to the vascular arcades. An area of retinal atrophy temporal to the fovea can also be seen.
Figure 2. Enlarged color photo of the peripheral retinal gyrate-like atrophy with pigment deposition.
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