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Table 1 Diagnostic Tests and Workup of Patient’s Vision Loss

From: Acute visual loss after ipilimumab treatment for metastatic melanoma

Time after initial ipilimumab treatment

Four months

Five months

Five and a half months

Six months

Fifteen months

Steriod Dosing/immunosuppression

Prednisone 40 mg with taper to 20 mg

 

Methyprednisolone IV 1 gram x 3 days, then prednisone 40 mg

Methyprednisolone IV 1 gram x 5 days, then prednisone 100 mg daily, tapered to 80 mg daily

Methylprednisolone

IV 1 gram daily x 10 days, then prednisone 100 mg daily, mycophenolate mofetil 1000 mg BID

Mycophenolate mofetil 1000 mg BID, slow prednisone taper

Ophthalmologic Exam

Left Eye -No light perception Vision; Left afferent pupillary defect; Optic nerve swelling; retinal whitening

Right Eye- visual acuity 20/50; decreased color vision; visual field

constriction; optic

disc swelling; Left eye

- vision remained no

light perception

Right Eye - subjective

vision improvement;

reduced optic disc

swelling; following

steroid treatment

Right Eye- declined

visual acuity

 

Right Eye - visual acuity 20/20; resolved optic disc swelling; Left Eye -no light perception; atrophic optic nerve

Magnetic Resonance Imaging

Unremarkable; No metastases

Unremarkable

 

Circumferential enhancement of intraorbital optic nerves, right > > left

Negative for brain metastases

 

Lumbar Puncture

Opening pressure

   

23

  

Cell count

 

WBC 62

RBC 2

WBC 69

RBC 1

WBC 42

RBC 1

 

WBC 7

RBC 0

Protein (normal 15-45)

 

104

96

51

 

32

Glucose (normal 40-70)

 

55

52

86

 

112

Infectious work-up

  

Fungal Cx neg; AFB stain neg; Crytpo Ag neg; HSV PCR neg; RPR neg; Lyme neg; CMV neg; VZV; neg; Bartonella neg

Cx neg

 

Cx neg

Cytology

  

Negative for malignancy

Negative for malignancy

 

Negative for malignancy

  1. Abbreviations: IV intravenous; BID twice a day, AFB acid fast bacili, CMV cytomegalovirus, Crypto - cryptococcus; Cx culture, HSV herpes simplex virus; neg - negative; RPR rapid plasma reagin (syphilis), VZV varicella zoster virus