DRESS Syndrome With Bilateral outer macular involvement: A Case of  acute visual loss

Background

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a rare, severe, multi-organ hypersensitivity reaction.
 Lamotrigine is a well-documented trigger.

Ocular involvement is uncommon, and macular scarring is extremely rare.
 This case describes rapid bilateral central visual loss secondary to DRESS syndrome in a young adult.

 

Case Presentation

Patient: 24-year-old female with a history of psoriasis
Medication: Lamotrigine for one month, prescribed as a mood stabiliser

Timeline of Symptoms:

09 Oct -  Lamotrigine commenced

09 Nov - lamotrigine discontinued

12 Nov - Oral prednisolone 40mg commenced

02 Nov  – Truncal morbilloform rash → spreading to face and full body over 6 days

5–11 Nov – Fever, dizziness, fogginess, general malaise; rash worsened with pressure

11 Nov – New onset of black spots in vision

 12 Nov - WCC 11.7, CRP 99, ALT 129, AST 84, Bilirubin 10.

12 Nov – Diagnosed with DRESS syndrome, started on Prednisolone 40 mg daily

20 Nov -  Progressive visual symptoms: difficulty recognising faces, floaters, and significantly blurred vision

 

Ophthalmic Examination

Visual Acuity (18/11/2025)  - 6/20 unaided either eye

Visual Acuity (20/11/2025) -  6/12 unaided either eye

Anterior Segment

 Conjunctival injection 11 Nov, resolved day 18 Nov

Lenses clear

No anterior or posterior chamber activity

Posterior Segment

Bilateral discrete islands of macular RPE change

OCT patches of change in the outer nuclear layer, external limiting membrane, ellipsoid zone and retinal pigment epithelium

No retinal vasculitis.  Normal peripheral retina

Findings consistent with possible choroiditis or retinal pigment epitheliopathy secondary to an immune reaction to Lamotrigine

 

Management

Lamotrigine discontinued

Initiated on Prednisolone 40 mg for X days, with tapering over X weeks

Dermatology and ophthalmology joint follow-up

Referral to:

Eye Care Liaison Officer

Sensory Support Services

Monitoring for progression of macular scarring and visual function