Case report
A 9-year-old boy, with a history of HLH from 6 months ago, was referred
by his pediatric oncologist to the ophthalmic emergency department with
a complaint of painless progressive blurred vision in his right eye. On
ocular external examination, there was a mild conjunctival injection,
chemosis, and proptosis in his right eye (Figure 1). The best-corrected
distance visual acuity was 20/40 and 20/20 for his right and left eye
respectively. The relative afferent pupillary defect (RAPD) examination
was positive for the right eye. Anterior segment examination was
unremarkable for both eyes. In the fundus examination, we found an optic
disc swelling and peripapillary hemorrhage in the right eye. The left
fundus examination showed a mild optic nerve head blurred margin.
Regarding the patient’s clinical status, differential diagnoses include
neoplastic infiltrative optic neuropathy, cytomegalovirus (CMV) optic
neuritis, drug toxicity, and CNS involvement with increased intracranial
pressure (ICP). For further evaluation, a brain and orbital MRI with
gadolinium enhancement (Figure 3), aqueous sampling with a 25-gauge
needle for polymerase chain reaction (PCR) to detect CMV, lumbar
puncture (LP) to analyze cerebrospinal fluid cytology and biochemistry,
and also for ICP measurement, and blood test for hematology and
biochemistry were ordered. We summarized the results of the patient’s
imaging and lab tests in Table 1.