Diagnostic and Therapeutic Challenges

Abstract

A 54-year-old white woman presented with a complaint of 4 days of painless loss of vision in the right eye. She has a medical history of high cholesterol and depression. Current medications include atorvastatin, paroxetine, calcium, vitamin D, and a multivitamin. The patient has a history of having oral cold sores approximately once a year. She does not have any genital ulcers. She also has had chickenpox, measles, and mumps. Her surgical history is significant only for bladder surgery for urinary problems after the delivery of her children. She works as a real estate agent and stated that recently she had been showing old homes that were under foreclosure and had moldy environments. She lives in Maryland but has spent time living in Iran, Turkey, and Switzerland. She has two dogs and owned a cat several years ago. She reports smoking one pack of cigarettes a day. The family history is noncontributory. A detailed review of systems is significant for a few white patches of skin on her forearms, easy bruising, sinus trouble, and shortness of breath at times.On examination, the visual acuity with correction was count fingers at 3 feet without improvement on pinhole in the right eye and 20/32 with improvement on pinhole to 20/25 in the left eye. Slit-lamp examination of the anterior segment was significant for 2ϩ conjunctival injection in the right eye and 1ϩ injection in the left eye. The right cornea had fine keratic precipitates, and the left cornea was clear. The right anterior chamber had 3ϩ cells and flare; the left anterior chamber had no cell but 1ϩ flare. The right iris had posterior synechiae inferonasally. There was 1ϩ nuclear sclerosis of the lens in each eye. Intraocular pressures measured 16 mmHg in the right eye and 14 mmHg in the left eye.Dilated funduscopic examination of the right eye showed a hazy view with multiple white, fluffy balls throughout the vitreous cavity (Figure 1, A and B). There was a limited view of the optic nerve, which was edematous. There were yellow chorioretinal lesions in the macula and throughout the peripheral retina. There were also intraretinal hemorrhages throughout the periphery. The yellow lesions and hemorrhages were predominantly involving the inferior half of the midperipheral retina. The left eye also had a few white, fluffy balls in the vitreous and an optic disk with mildly blurry margins. The macula was without edema or lesions ( Figure 1C). There were sclerotic vessels extending off of the superotemporal and inferotemporal arcades ( Figure 1D). The midperiphery was notable for intraretinal hemorrhages. Fluorescein angiography transiting the left eye showed evidence of vasculitis and disk leakage ( Figure 1E). Questions1. What is your differential diagnosis? In particular, how does the presence of the fluffy balls in the vitreous cavity and the medical history affect the differential diagnosis? 2. What are the most important laboratory or imaging investigations that you would like to initiate? 3. If diagnostic vitrectomy is nondiagnostic, then would you consider...

Practical diagnostic approach to uveitis

“…Other causes of panuveitis include Behçet's disease, sarcoidosis and infectious endophthalmitis [1,14,17,41,48,89,104,105]. Infectious endophthalmitis may initially present with vitritis, but typically a severe inflammation involving all ocular structures is observed.…”