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A 54-year-old Caucasian male was referred to our clinic complaining of a significant loss of central vision in his right eye. Upon examination, his visual acuity was 5/200 in the right eye and 20/25 in the left; IOP was 14 mmHg in both eyes, and the color saturation in the right eye was decreased. Peripheral fields were unaffected, but a large central scotoma was present in the right eye. Funduscopic exam revealed a blurred nasal disc margin in the right eye indicative of optic nerve edema. A large portion of the macula appeared slightly hypopigmented. This yellowish area fit the approximate contours of the scotoma.
The initial impression was choroiditis with associated optic neuritis. The patient admitted to being HIV-positive. His CD4 count from the previous month was normal and his viral load was undetectable. OCT showed a normal foveal contour—though red-free fundus photographs revealed flecking within the macula. Serologic tests came back positive for syphilis. After treatment with penicillin, his visual acuity was 20/40 and improved to 20/25 five months later.
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