Differential Diagnosis for Sudden Central Vision Loss

The patient's symptoms of sudden central vision loss in one eye, followed by the other, with a family history of similar vision loss in males on the mother's side, suggest a range of potential diagnoses. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Leber's Hereditary Optic Neuropathy (LHON): This condition is a mitochondrial inherited disorder that predominantly affects young adult males, leading to central vision loss, often starting in one eye and then affecting the other. The family history of central vision loss in males on the maternal side strongly supports this diagnosis, as LHON is inherited through mitochondrial DNA, which is passed from mother to child.

• Other Likely Diagnoses

  • Optic Neuritis: An inflammation of the optic nerve that can cause sudden vision loss, including central vision loss. It's more common in young adults and can be associated with multiple sclerosis, though the bilateral and sequential nature of the patient's symptoms is less typical.
  • Compressive Optic Neuropathy: Conditions such as tumors or thyroid ophthalmopathy can compress the optic nerve, leading to vision loss. However, these conditions usually have other associated symptoms and signs.

• Do Not Miss Diagnoses

  • Giant Cell Arteritis: Although less common in an 18-year-old, giant cell arteritis can cause sudden vision loss, including central vision loss, and is a medical emergency requiring prompt treatment to prevent further vision loss.
  • Diabetic Retinopathy: In the context of undiagnosed diabetes, diabetic retinopathy can lead to sudden vision changes, including central vision loss. Given the potential for diabetes to be asymptomatic until complications arise, considering this diagnosis is crucial.

• Rare Diagnoses

  • Toxic or Nutritional Optic Neuropathy: Certain toxins (e.g., methanol, ethambutol) or nutritional deficiencies (e.g., vitamin B12 deficiency) can cause optic neuropathy leading to central vision loss. The sequential nature of the vision loss in this patient makes this less likely but still worth considering, especially if there's an exposure history.
  • Inherited Retinal Diseases: Such as Stargardt disease or cone-rod dystrophy, which can cause central vision loss but typically have an earlier onset and may involve peripheral vision as well.
  • Syphilis: Neurosyphilis can cause optic neuropathy, among other neurological manifestations. Given the increasing incidence of syphilis, considering this diagnosis, especially if other risk factors are present, is prudent.