Acute Macular Neuroretinopathy

A 43-year-old male presented as urgent referral for bilateral central vision loss. His past medical history was significant for Crohn’s disease Symptoms of fever, headache and myalgia began one week prior following a tick bite. He was placed on oral doxycycline for suspected Lyme disease. Due to persistent fever on oral doxycycline, he was admitted for IV doxycycline and fever resolved.  While hospitalized, he acutely developed bilateral central scotoma. 

Ocular exam revealed acuity of 20/50 OD and 20/60 OS. The infared and OCT images are below. What is the diagnosis?

Acute macular neuroretinopathy (AMN) was initially described in a 1975 case series of 4 young women presenting with mildly reduced visual acuity, acute onset paracentral scotomas and red-brown, wedge-shaped macular lesions on fundoscopy; all 4 women were on oral contraception. Since then, additional environmental triggers have been reported including recent infection/flulike illness (47.5%); oral contraception (35.6%); and less commonly, sympathomimetic exposure such as caffeine and ephedrine (7.9%), septic shock (5%) and severe nonocular trauma (5.9%). AMN exhibits gender, race, and age predilections with young (mean age = 29), Caucasian females being most frequently affected.2 The process can be bilateral (55%) or unilateral (45%), and scotoma is the chief complaint in most (72.3%) cases.

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