A 21-year-old female presented with a one-month history of severe left eye pain, associated with headaches and a 2-week history of gradual reduction of vision. Her history was positive for unexplained weight loss of 2 years  duration, remitting and relapsing suppurative cervical masses, loss of appetite, nausea and vomiting after meals. She had no history of low grade fevers, night sweats, rashes, exposure to persons with chronic cough or exposure to cats. She is a chronic severe peptic ulcer disease patient on medication. The patient recently, abruptly, relocated from the northern part of Nigeria, at the commencement of the COVID-19 pandemic lockdown, two months before presentation. She had previously sought medical care on account of the weight loss and neck masses. All investigations carried out were non-revealing, by her account. She did not possess copies of these results, a medical report or the contact information for her previous physician. She delayed presentation to an eye-care provider, at the onset of her ophthalmic symptoms, due to the temporary closure of most private eye hospitals during the first phase of lockdown. She did not present at any public eye-care emergency hospitals in order to avoid contact with crowds of people, as a preventive measure against contracting the COVID-19 virus.
On general physical examination, the patient was chronically ill looking and she had multiple, visibly enlarged cervical and supraclavicular lymph nodes bilaterally (each ~ 5 x 3cm). The left enlarged supraclavicular lymph node was ulcerative, with purulent discharge. Significant eye examination findings were best corrected visual acuity of 6/9 in the right eye and no perception of light (NPL) in the left eye. Extraocular motility was full in both eyes, however there was left eye pain with movement. The left pupil was dilated and unreactive to light. There was no sign of anterior segment or vitreous inflammation. Fundus examination showed remarkable optic disc and macular swelling, with a 'macular fan' hard exudates (lipid deposition). The right eye examination was normal. Multiple tests were ordered, including complete blood count and blood film, Flourescent Treponemal Antibody Absorption (FTA-ABS), Angiotensin Converting Enzyme (ACE), Lyme serology, TB-quantiferon gold-assay and Retroviral screening tests. Fundus photography and orbital B-scan tests were scheduled to be carried out peripherally as ocular investigations at our facility had been suspended. However, a quick baseline fundus photograph of the left optic nerve head was taken in the clinic, using the iPhone XR mobile phone and 20D Volk lens (Figure 1). Empirical oral ciprofloxacin was commenced pending the return of the test results. A two-day follow-up appointment, for the review of the test results, was scheduled. Patient returned to the clinic after two weeks. Laboratory services had been disrupted by the pandemic lockdown and she chose not to return without the investigation results. Her TB-quantiferon gold assay result was positive while other test results were non-revealing. The ocular investigations had not been carried out. Ocular examination remained status quo.
At this visit, patient revealed that prior to the pandemic-lockdown; plans for a clinical trial of Anti-Tuberculosis-Therapy (ATT) had been instituted by her previous physician. These plans were disrupted by the onset of the lockdown and her subsequent unplanned relocation. The patient was urgently referred to an IDS, through her new primary care physician, with recommendations for prompt initiation of ATT. Oral steroid therapy was deferred till after the start of ATT. Clearance for the initiation of steroid therapy was requested from the IDS. Her history of severe chronic severe peptic ulcer disease was noted as a relative contraindication to the therapy. Ocular investigations were re-scheduled and a one-week follow up clinic appointment was scheduled. She presented for a third clinic visit after 4weeks. Quadruple therapy of ATT (Rifampicin, Isoniazid, Pyrazinamide and Ethambutol) had been instituted for four weeks. Patient declined to come in sooner, in her continued bid to reduce her risk for COVID-19 infection. She had also defaulted from the follow up appointment with the IDS. Her clinical appearance was much improved at this visit- appetite was restored, post-meal vomiting resolved, weight gain ~ 2.5kg and suppurative lymph nodes had healed. Visual acuity in the left eye was Hands-Motion with sluggish pupillary constriction to light observed. There was complete resolution of the optic nerve and retina swelling, with waxy disc pallor, residual hard exudates at the macula, macular hyperpigmentation and thinning.
Efforts to obtain the contact information for the IDS, for an interdisciplinary consult, proved abortive. A follow-up letter was sent, repeating the request for clearance for oral steroid therapy. The option of periocular steroid administration was discussed with the patient. A follow up clinic appointment of 1 week was scheduled. Patient returned 1 week later, as scheduled (5 weeks on ATT). Vision had deteriorated back to NPL. Fundal optical coherence tomography (OCT) testing was carried out at this visit. The findings in the left eye were severe thinning of the outer and inner retinal layers with loss of the foveal contour (Figure 2,Figure 3). Patient was still yet to present for a follow-up appointment with the IDS, due to the reasons stated earlier. A third letter was written, to the IDS, with an update about her condition and a request for an interdisciplinary phone consult. Independent efforts made by our clinic to obtain the name and contact information of the IDS have been yet unsuccessful. Weekly follow up consultations via video-conferencing have been set up. Patient was encouraged to keep her appointment with the IDS.