Bilateral optic disc swelling in a man aged 32 years

Amale propertyagentaged 32 years presented to his general practitioner (GP) with a history of blurred vision worsening over the preceding three months. The patient had noted his vision in both eyes was blurry, particularly when alternating from brightt o dark environments. He had been recently well, but reported increased work-related stress in the preceding months. The patient denied headaches, nausea, vomiting and previous sensory or motor disturbances. He had been in a stable relationship for over five years butacknowledged he might have had prior unprotected sexual exposures. The patient was otherwise well, took no regular medications, had no known allergies or significant family history. On examination, his blood pressure was 118/78 mmHg and random blood glucose was 4.8 mmol/L. Neurological examination showed normal reflexes, muscle tone and power in all four limbs. The cranial nerve examination was normal, as was the remainder of the physical examination. Visualisation of the optic discs was limited with direct fundoscopy without access to dilating drops. The patient was referred for urgent ophthalmology review. The patient was seen by an ophthalmologist who, reported a corrected visual acuity of 6/7.5 in each eye, with no pinhole improvement. Pupil reactions were normal in each eye, and there was no relative afferent pupillary defect. There was a full range of extraocular movements and no ptosis or proptosis. Anterior segment examination was unremarkable. Fundus examination revealed bilateral blurred optic disc margins. There were retinal folds in the right eye and retinal nerve fibre layer haemorthages in the left eye. An abnormal vascular pattern was noted suggestive of optic disc neovascularisation (Figure 1). This can be a useful retinal findingi n the diagnosis of neurosyphilis.' The appearance was consistent with severe bilateral optic disc swelling, which was confirmed with optical coherence tomography (OCT) scanning of the optic nerves. Automated perimetry showed impaired visual fields bilaterally.