1332hrs: Posterior Uveitis/Sympathetic Ophthalmia (Bernard Hurley)
/Top 10 cases of posterior uveitis and what they have taught the speaker.
Case 1:
26 yo WM with blurry vision x 3 days. Granulomatous KPs, conj redness, 2+ cells, vitritis. Therefore a pan-uveitis.
Tb, Sarcoid, Syphilis, Lyme and others
All tests came back negative
Additional information: friend had lit a firecracker near his eye several weeks prior to uveitis presentation that did have exposed uvea other eye. Therefore, this patient had sympathetic ophthalmia! Bilat panuveitis develops 2-8 wks after initial injury. Used to be commonly made diagnosis around US civil war time. Much less seen now, likely mis-diagnosed in past. More aggressive surgery today with surgery that can expose uvea. Dalen-Fuchs nodules are the classic finding that’s been described in the fundus.
Therapy includes topical steroids and intravitreal and other immunosupressants. Is the trauma more of a red herring?
Case 2:
25 yo WF poor vision OD, diagnosed by resident with macular hole. Colour photos show circular change both maculas but more diffuse retinal change is the pathology. Early hypofluorescence with later hyperfluorescence on angiogram. This is the pattern of inflammation as part of white dot syndromes including AMPPE, MEWDS, Birdshot, etc. - AMPPE
AMPPE multiple cream coloured lesions, equal prevalence male & female with good outcome. MEWDS tends to be more in myopic, female, younger and is uniocular with enlarged blindspot b/o papillitis. Birdshot, is a terrible form of uveitis that comes back and is difficult to control with strong HLA A29 correlation. Multifocal choroditis looks like Histo but has inflammation associated with it. POHS caused by an infectious agent. Serpigenous also very aggressive, starting peripillary or macular then spread.
Case 3:
24 yo WF shows the FA of another white dot syndrome unilateral in young female: MEWDS
Case 4:
16 yo F who noted large blind spot suddenly right eye, saw 2 ophthalmologists recently. Fullness to disc with margins not as distinct affected eye. Both right and left eye can tell myopic fundi based on the FA. On dilated fundus exam, can actually see lots of white dots, many near the disc. Another case of MEWDS.
Case 5:
15 you BF decreased VA x 2 days with VA 6/9 and 6/120. Scarred retina central burnt out area with creamy white infiltrate at all borders of the lesions. Other eye normal til dilate and look nasally were see active white fluffy border. Serpigenous Choroidopathy…a destructive, chronic condition. This does poorly. But, this seems young for serpigenous, so did limited workup done to check for Syphilis which showed +ve FTA-ABs.
Case 6:
37 yo hispanic male more of a vitritis, definite focii inflammation in the retina. Snowballs inferiorly in the better eye. Bad eye had a hypopyon. Systemically had penile rash. Diff Diag: Bechets’, Tb, Syph, Sarcoid, Lyme and turned out to be Syphilis. Afterwards did learn that he was knowingly HIV +ve as well.
Case 7:
Another case this time subtle subretinal lesion but once dilate see white dots and peripapillary atrophy more easy to appreciate. This is CNVM, young patient so consider POHS. No vitiritis with this condition. Know the organism.
Case 8:
6/24 vision with peripheral vasculitis with adjacent old scar. Fellow eye very healthy. This patient has toxoplasmosis treated with clindamycin and pred along with topical tx. Not all reactiviated from childhood, can be acquired.
Case 9:
46 yo animal control officer with swollen nerve one side. FA shows hot spot on optic disc. Sarcoid, syph, Tb, toxo. Eveolved to be more obvious as cat-scratch (Bartonella)
Case 10:
40 yo M worked up for PSCC and noted changes in fundus. White lesions along blood vessels; white lesions with haemmorhagic centres along blood vessels. CMV retinitis. Can treat with oral valganciclovir. Can get very bad pan-retinitis when immune system working again.
Also mentions PORN (progressive outer retinal necrosis)
Case 11:
Referred by optom with central serous chroid retinopathy. But, angiogram shows cystoid macular edema.