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Quiz: The White Feathery Mystery

Test your understanding of this case with 10 questions.

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Case Information
Review the case details while answering questions

PATIENT DEMOGRAPHICS

68-year-old male

PRESENTING COMPLAINT

Episodes of transient visual loss in the right eye. Patient reports occasional brief episodes where vision becomes unclear, lasting a few seconds to minutes before returning to normal.

EXAMINATION FINDINGS

Visual Acuity: OD: 6/6, OS: 6/6

Pupils: Equal, reactive, no RAPD

Fundus: OD: White feathery streaks extending from optic disc margin into retina, consistent with medullated nerve fibres. Retinal vessels clearly visible coursing through lesions. OS: Similar but less extensive changes

INVESTIGATIONS

Left fundus showing white feathery streaks of myelinated nerve fibers extending from the optic disc with less extensive involvement

Left fundus showing white feathery streaks of myelinated nerve fibers extending from the optic disc with less extensive involvement

Right fundus demonstrating more extensive white feathery myelinated nerve fibers radiating from the optic disc margin

Right fundus demonstrating more extensive white feathery myelinated nerve fibers radiating from the optic disc margin

Fundus Photography: Bilateral medullated nerve fibres visible as white feathery streaks radiating from the optic disc margins. Right eye shows more extensive involvement than left eye. Retinal vessels are clearly visible coursing through the white lesions, which is characteristic of this benign congenital anomaly.

OCT Retinal Nerve Fiber Layer: Hyperreflective thickened nerve fiber layer in affected areas corresponding to the medullated fibers seen clinically. Normal retinal architecture in unaffected areas.

Visual Field Test (Humphrey 24-2): Bilateral enlarged blind spots corresponding to the areas of medullated nerve fibers. No other field defects detected. Peripheral fields remain intact.

Fundus Autofluorescence: Areas of medullated nerve fibers show hypoautofluorescence, confirming the presence of myelinated tissue anterior to the lamina cribrosa.

Question 1 of 10

The patient describes episodes of blurred vision in the right eye lasting seconds to minutes before fully returning to normal. This history is most consistent with which of the following?

Question 2 of 10

Which feature helps differentiate myelinated retinal nerve fibres from cotton wool spots?

Question 3 of 10

Which feature most argues against optic disc drusen as the cause of this fundus appearance?

Question 4 of 10

Fundus autofluorescence shows hypoautofluorescence in the affected areas. What does this most directly confirm?

Question 5 of 10

What is the most likely diagnosis?

Question 6 of 10

Under normal development, oligodendrocyte myelination of the optic nerve fibres stops at which structure?

Question 7 of 10

Regarding the myelinated nerve fibres specifically, what management is required?

Question 8 of 10

The patient's transient monocular visual loss requires separate urgent investigation from the incidental myelinated nerve fibre finding. What is the most appropriate next step?

Question 9 of 10

What is the expected long-term course of myelinated retinal nerve fibres?

Question 10 of 10

On fundus examination alone, before any investigations, what single feature would most reliably distinguish myelinated nerve fibres from early bilateral papilloedema?