Clinical Presentation

A 64-year-old white woman presents with a 2-week history of a visual field defect. She does not report any associated blurred vision, diplopia, or pain in either eye, other than occasional bilateral conjunctival injection, which she attributed to allergies.

The patient has a history of seizures in childhood and a surgical history of cesarean section. She was taking simvastatin 40 mg daily and 0.25 mg alprazolam as needed. She reported no known allergies. She was an “every day smoker” but did not specify the number of pack-years. There was a family history of cataracts in her brother, sister, and father. Her brother had a history of macular degeneration, and her paternal grandmother had a history of breast cancer at an unspecified age.

Best-corrected visual acuity was 20/20 in each eye. Color plates were 10/10 bilaterally, and Amsler grid was normal in each eye. Visual field testing by confrontation suggested a temporal defect in the left eye. Automated perimetry showed an incomplete right superior quadrantanopia (Figure 1).



Figure 1. Automated perimetry.

The intraocular pressure was normal in both eyes. No relative afferent pupillary defect was present, and the pupils measured 3 mm in the dark and 2 mm in the light bilaterally with brisk reaction to light. Slit-lamp examination revealed nuclear sclerotic cataracts bilaterally. Funduscopy was normal in each eye.

An MRI of the brain with contrast revealed an abnormal 3 cm x 3 cm area involving the left occipital lobe, with a dilated left lateral ventricle (Figure 2).



Figure 2. An axial MRI with FLAIR sequences.





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