History of present illness
A 36-year-old female patient with an unremarkable past medical history and past ocular history presents with blurry vision of both eyes. Her symptoms were acute in onset and have been progressive over the past week. She endorses generalized malaise, fatigue, mild photophobia, and worsening headaches.
Ocular examination findings
Visual acuity with correction was 20/200 in the right eye and 20/60 in the left eye, with no improvement with pinhole. Intraocular pressure was normal at 12 and 14, respectively. Pupils were round, equal, and reactive without a relative afferent pupillary defect. External examination was unremarkable. Anterior segment examination showed trace anterior chamber cell and flare in both eyes but otherwise was unremarkable. Dilated fundus examination showed vitreous cell in both eyes. Both optic nerves appeared hyperemic with mild blurring of the disc margins. Cystoid macular edema along with subretinal fluid was appreciated in the macula region. Vessels appeared mildly tortuous but with normal course and caliber. Shallow inferior subretinal fluid was appreciated in the periphery of both retinas.
Questions to ask
- ■
What is the patient’s ethnic background? There is thought to be a genetic predisposition to the pathogenesis of Vogt-Koyanagi-Harada (VKH) disease. Multiple interleukin genes and human leukocyte antigens are associated with VKH in different ethnic populations, especially in Asian, Middle Eastern, Native American, and Hispanic populations. , The typical age of onset is between 20 to 50 with a woman predisposition.
- ■
The patient was Hispanic and in her mid-30s.
- ■
- ■
Does the patient have prodromal symptoms? Uveitic conditions such as acute posterior multifocal placoid pigment epitheliopathy (APMPPE) may present with prodromal symptoms such as headaches, fever, nausea, tinnitus, and neck stiffness.
- ■
The patient reported generalized malaise, fever, and headaches 4 days before the development of ocular symptoms.
- ■
- ■
Does the patient have a history of ocular trauma or previous surgery? History of ocular trauma or intraocular surgery should be obtained in the consideration of sympathetic ophthalmia, which may have a similar ocular presentation and shared pathophysiology to VKH.
- ■
None
- ■
- ■
What medications does the patient take? High-dose steroids may precipitate subretinal fluid accumulation in the setting for central serous chorioretinopathy.
- ■
None
- ■
- ■
What is the patient’s refractive error? Nanophthalmic eyes are at risk for developing uveal effusion syndrome.
- ■
The patient had myopia, wearing −3.25 D prescription glasses.
- ■
Assessment
- ■
This is a case of a 36-year-old Hispanic female patient with no past ocular or surgical history presenting with generalized malaise and bilateral serous retinal detachments.
Differential diagnosis
- ■
Vogt-Koyanagi-Harada (VKH) disease
- ■
APMPPE
- ■
Sympathetic ophthalmia
- ■
Central serous chorioretinopathy
- ■
Panuveitis secondary to infection (e.g., syphilis, tuberculosis, Bartonella ), secondary to autoimmune conditions (sarcoidosis, systemic lupus erythematosus) or secondary to malignancy
- ■
Posterior scleritis
- ■
Myopic retinoschisis
- ■
Optic pit maculopathy
Working diagnosis
- ■
VKH disease
Multimodal testing and results
- ■
Fundus photographs
- ■
Color fundus photographs were taken at presentation: right eye with disk edema and hyperemia along with subretinal fluid extending from the disk temporally through the macula ( Fig. 31.1 ). Focal serous retinal detachment was noted inferiorly as well. The left eye had disk edema, hyperemia, and an inferior serous detachment ( Fig. 31.2 ).
- ■
