Given the unilateral disc hyperemia, vision changes, systemic vascular risk factors, and recent high-altitude exposure, initial consideration was given to a potential diagnosis of an incipient non-arteritic anterior ischemic optic neuropathy (NAION) 1 in the left eye. The mild asymmetry between eyes on exam and fundus imaging warranted optical coherence tomography (OCT) imaging. Optical coherence tomography of the left eye ( Figure 2 ) reveals peripapillary adhesion and traction of the posterior hyaloid with schisis of the nerve fiber, ganglion, inner nuclear, and outer nuclear layers, without subretinal fluid, ultimately leading to a diagnosis of vitreomacular peri/papillary traction syndrome. Serological testing was performed and the patient’s complete blood count (CBC), basic metabolic panel (BMP), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), as well Syphilis, TB quantiferon, anti-neutrophil cytoplasmic antibodies (ANCA), Sjögren’s-syndrome-related antigen A SSA (Ro), Sjögren’s-syndrome-related antigen B SSA (La), and Bartonella were negative, whereas angiotensin-converting enzyme (ACE) was elevated (93 U/L). Recent exposure to high altitude, which is associated with hypoxia and transient alterations in microvascular perfusion 2 , 3 , 4 , may represent a relevant contextual factor in the setting of tractional deformation of peripapillary vessels, although a causal relationship cannot be established. High altitudes can also increase the risk of developing a NAION. The patient was referred to the retina service for vitreomacular traction (VMT). Pars plana vitrectomy was not recommended due to preserved visual function and lack of foveal involvement 5 , 6 , with additional concern for surgical release of vitreopapillary traction precipitating iatrogenic nerve fiber damage in eyes with small optic nerve cups, although this is controversial 7 . While the finding of vitreopapillary traction was severe, the patient was advised to follow up regularly for surveillance. This case emphasizes the importance of considering a dilated exam to rule out alternative structural or anatomic abnormalities in patients presenting with presumed optic disc edema or hyperemia. Vitreomacular traction (VMT) typically occurs in patients with macular diseases such as diabetic retinopathy, diabetic macular edema, age-related macular degeneration, and inflammatory eye diseases. Over time, the vitreous gel undergoes age-related condensation, including liquefaction and loss of volume, leading to traction on retinal and papillary attachments. Signs associated with vitreous traction include intraretinal and subretinal fluid, as well as the development of an epiretinal membrane 8 . Share Image:
Abdelmalek et al. (Sat,) studied this question.