Working Diagnosis:
Optic Neuritis due to mycoplasma infection

Treatment:
Patient was admitted to the hospital for three days of high dose IV steroids. The vision, painful ocular movement, and headache improve. He was then discharged home with a four-week steroid taper and pending CSF results. Asymptomatic three weeks after discharge. CSF studies result positive for IgM Mycoplasma Antibody.

Outcome:
He fully recovered. A follow-up MRI was normal. He returned to soccer.

Author's Comments:
Half of the brain’s circuits are visual. Fifty percent of traumatic brain injury patients suffer from visual dysfunction and one such study found a 90% incidence. We feel that the vision assessment is often neglected. Many concussive symptoms are not specific to concussion. Therefore, vision defects may herald other diagnoses. In this case the left-sided blurriness and pain with extra-ocular movements should warrant further investigation.

Editor's Comments:
This case stresses the need to be mindful of common clinical symptoms that overlap. As the author points out, loss of vision in a marked pattern (almost like a left homonymous hemianopia) is not typical, especially worsening on day 12 post concussion. The typical pattern of concussion vision changes is blurry vision, double vision, and light sensitivity (4). Therefore, when the clinical history does not fit the usual pattern, an alternative diagnosis should be considered. In this case, the medical team worked closely with the neurologist and ophthalmologist, and thankfully had a good outcome for the patient.

References:
Ventura RE, Balcer LJ, Galetta SL. The Concussion Toolbox: The Role of Vision in the Assessment of Concussion. Semin Neurol. 2015 Oct;35(5):599-606. doi: 10.1055/s-0035-1563567. Epub 2015 Oct 6. PMID: 26444405.
Ciuffreda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, Craig S. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry 2007;78(4):155-61
Choi SY, Choi YJ, Choi JH, Choi KD. Isolated optic neuritis associated with Mycoplasma pneumoniae infection: report of two cases and literature review. Neurol Sci. 2017 Jul;38(7):1323-1327. doi: 10.1007/s10072-017-2922-9. Epub 2017 Mar 20. PMID: 28321515.
Adams, E. "Visual problems in traumatic brain injury: A systematic review of sequelae and Interventions for the Veteran population." Vision TBI Final Report. Department of Veterans Affairs, Washington, DC (2009).

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