Blurred vision: targeting a diagnosis

A 68 year old woman with a longstanding history of non-specific inflammatory arthritis (which had been extensively investigated) was referred to the ophthalmologist with a three month history of flashing lights and blurred vision. Her regular drugs included meloxicam, omeprazole, amitriptyline, and 400 mg hydroxychloroquine, which she had been taking daily for 15 years. She was of normal body weight.

Ophthalmological assessment showed a reduced visual acuity at 6/18 in the right eye and 6/12 in the left eye, with mild depression in colour vision on Ishihara plate testing. Early cataracts were present, and fundal examination identified bilateral changes in epithelial retinal pigment at both posterior poles.Visual field testing showed bilateral annular scotomas.

She was referred for further investigations, including colour fundus photography, which show bilateral disturbance of retinal pigments at both maculas giving a “bull’s eye” appearance (fig 1⇓)