A 60-year-old, right-handed man presents with visual loss.

A 60-year-old, right-handed man presents with visual loss. About 2 weeks before, he began to notice difficulty seeing the television. Within 1 week, he noticed that the inferior field of vision in the right eye was much worse than the top of his vision. Within a few more days, he noticed the bottom of the vision in his left eye worsen as well. This has been painless. He has otherwise felt well, without headaches or cognitive changes. An ophthalmologist saw bilateral papillitis with white exudates of the nasal part of the discs. There is no history of alcohol use, and the patient has stopped smoking since his heart transplant. On examination, he appears well. Blood pressure is 160/80 mm Hg; pulse is 100 beats per minute and regular. There are no carotid bruits. Pupils are equal and reactive. Visual acuity is 20/400 OU, with central-inferior scotomas (left larger than right). Neurologic examination is otherwise normal. An MRI scan with and without gadolinium contrast agent, including orbital cuts, is negative, as is CSF examination. This patient’s history, examination, and laboratory findings are now most consistent with which of the following diagnoses?

a. Cyclosporine toxicity

b. Occipital lobe lymphoma

c. Tobacco-alcohol amblyopia

d. Ischemic optic neuropathies

e. Retinal detachment

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