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A 32-year-old woman comes to the office distraught because "the colors look washed
out!" She has had this vision impairment since yesterday. She also complains of pain on
eye movements. Her vital signs are stable, and she is afebrile. Examination reveals
decreased visual acuity, sluggish afferent pupillary response to light, and changes in
color perception. Fundoscopy reveals a swollen disc. What is the most likely diagnosis?

o A Orbital cellulitis
o B. Optic neuritis
o C. Acute anterior uveitis
o D. Open angle glaucoma
o E. Episcleritis

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A 32-year-old woman comes to the office distraught because "the colors look washed
out!" She has had this vision impairment since yesterday. She also complains of pain on
eye movements. Her vital signs are stable, and she is afebrile. Examination reveals
decreased visual acuity, sluggish afferent pupillary response to light, and changes in
color perception. Fundoscopy reveals a swollen disc. What is the most likely diagnosis?

A. Orbital cellulitis [6%)

B. Optic neuritis [72%)

C. Acute anterior uveitis [8%)

D. Open angle glaucoma [11%)

E. Episcleritis [3%)

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Explanation: User
Optic neuritis typically presents in people aged 20-45 years. Females are more
commonly affected. Patients experience rapid impairment of vision in one eye (or rarely
both) and pain on eye movement. There are marked changes in color perception.
Afferent pupillary defect and field loss occur, usually with central scotoma. Optic neuritis
is more common in patients with multiple sclerosis; such patients will usually give a
history of similar occurrences in the past.
(Choice A) Orbital cellulitis refers to infection posterior to the orbital septum. These
infections are unilateral and more common in children. It presents as an abrupt onset of
fever, proptosis, restriction of extraocular movements, and swollen, red eyelids.
(Choice C) In anterior uveitis, the eye is usually painful and red, with blurring of vision.
Typically, the eye has perilimbal injection. Examination reveals keratic precipitates.
Corneal stromal edema may be present.

(Choice D) Open angle glaucoma is characterized by gradual loss of peripheral vision

resulting in tunnel vision. Ophthalmoscopy shows pathologic cupping of the optic disc.
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B. Optic neuritis [72%]

C. Acute anterior uveitis [8%]

D. Open angle glaucoma [11%]

E. Episcleritis [3%]

' . ..
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Explanation: User
Optic neuritis typically presents in people aged 20-45 years. Females are more
commonly affected. Patients experience rapid impairment of vision in one eye (or rarely
both) and pain on eye movement. There are marked changes in color perception.
Afferent pupillary defect and field loss occur, usually with central scotoma. Optic neuritis
is more common in patients with multiple sclerosis; such patients will usually give a
history of similar occurrences in the past.

(Choice A) Orbital cellulitis refers to infection posterior to the orbital septum. These
infections are unilateral and more common in children. It presents as an abrupt onset of
fever, proptosis, restriction of extraocular movements, and swollen, red eyelids.
(Choice C) In anterior uveitis, the eye is usually painful and red, with blurring of vision.
Typically, the eye has perilimbal injection. Examination reveals keratic precipitates.
Corneal stromal edema may be present.
(Choice 0) Open angle glaucoma is characterized by gradual loss of peripheral vision
resulting in tunnel vision. Ophthalmoscopy shows pathologic cupping of the optic disc.
(Choice E) Episcleritis is an inflammation of the episcleral tissue between the
conjunctiva and sclera. There is an acute onset of mild to moderate discomfort,
photophobia, and watery discharge. Examination reveals diffuse or localized bulbar
conjunctival injection, and episcleritic nodules may be present.
Educational Objective:
Suspect optic neuritis in a patient with central scotoma, afferent pupillary defect, changes
in color perception and decreased visual acuity. Remember the association between
optic neuritis and multiple sclerosis (The USMLE loves this topic!).

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