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A 24-year-old woman with blurred vision and eye pain
Digital Journal of Ophthalmology 2008
Volume 14, Number 16
August 18, 2008
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Aristeidis Konstantinidis | Royal United Hospital Bath, UK
Ioannis Athanasiadis | Milton Keynes General Hospital, UK
Nikolaos Kozeis | Hippokarateio General Hospital , Greece
Claire Workmann | Coventry & Warwickshire University Hospital, UK
Yajati Ghosh | Coventry & Warwickshire University Hospital, UK
Differential Diagnosis
• Multiple sclerosis (MS)
• Space occupying lesion (e.g.tumours, aneurysms, arachnoid cysts or hydrocephalus)
• Vasculitis (e.g. systemic lupus erythematosus)
• Inflammation (e.g. sarcoidosis)
• Trauma
• Vitamin B12 deficiency
• Empty sella syndrome
• Pathological myopia

The diagnoses of space occupying lesion and empty sella syndrome were excluded after the initial scans. Our patient did not give a history of trauma and the diagnosis of vitamin B12 deficiency was also excluded as she did not have any symptoms consistent with vitamin B12 deficiency and its serum levels were normal.

Sarcoidosis was not likely to be the cause of the scotoma as chest X-ray did not reveal any relevant signs and angiotensin converting enzyme levels were normal. Pathological myopia was an unlikely diagnosis according to the fundoscopic and intravenous fluorescein angiogram findings.

Vasculitis was a possible diagnosis along with multiple sclerosis. Systemic lupus erythematosus (SLE), albeit rare, is a well established cause of chiasmatis in the international literature.(1,2,3) It can affect the visual pathway by either thrombosis of the visual pathway vasculature or by immunological mechanisms such as vasculitis.(3) Both mechanisms cause ischemia of the affected structures. The differential diagnosis between MS and SLE becomes more confusing by the fact that involvement of the central nervous system by SLE can cause the development of multiple areas of increased signal intensity in the subcortical white matter on T2 weighted images.(1) In addition to that, there is clinical overlap between neurologic manifestations of MS and SLE. Furthermore 81% of patients with MS are positive for antinuclear antibodies (ANA).(2)

In the case of our patient, ANA and anti-double strand DNA antibodies were negative and medical history and systematic examination did not reveal symptoms or signs of SLE. The course of the disease confirms the diagnosis of MS.