From the Research
For a 16-year-old with bilateral painless vision loss in the emergency department, I recommend immediate ophthalmology consultation while initiating a focused workup, including a thorough history, complete eye examination, urgent neuroimaging, and laboratory studies, as this presentation could indicate serious conditions like demyelinating disease, Leber's hereditary optic neuropathy, or intracranial pathology. The patient's symptoms and age suggest a potential autoimmune or inflammatory cause, and a thorough workup is necessary to establish the correct diagnosis and treatment. Key steps in the workup include:
- Conducting a thorough history focusing on onset, progression, associated symptoms, and recent illnesses
- Performing a complete eye examination including visual acuity, pupillary responses, visual fields, and fundoscopy
- Ordering urgent neuroimaging (preferably MRI brain and orbits with contrast) to rule out compressive, inflammatory, or demyelinating lesions
- Laboratory studies should include complete blood count, metabolic panel, inflammatory markers (ESR, CRP), and consideration of specific tests like ANA, ANCA, and NMO-IgG, as seen in cases of Vogt-Koyanagi-Harada disease 1 and other autoimmune conditions. If optic neuritis is suspected, which is common in this age group, administering high-dose IV methylprednisolone (typically 1 gram daily for 3-5 days) after consultation with ophthalmology and neurology may be necessary, as supported by the most recent study 2. However, the specific treatment should be guided by the underlying cause, which may require further investigation, including genetic analysis for Leber hereditary optic neuropathy mutations 3 or testing for thiamine levels in cases of suspected Wernicke-Korsakoff syndrome 2. Prompt diagnosis and treatment are crucial as delay could result in permanent vision loss.