History of Present Illness
A 24-year-old female presents with a known history of granulomatosis with polyangiitis (GPA), with prior laboratory tests positive for perinuclear antinuclear antineutrophil cytoplasmic antibodies (p-ANCA). Her systemic manifestations of GPA included oral ulcerations, pulmonary nodules, pericarditis, and hematuria. She had previously been treated with oral prednisone and methotrexate, although the methotrexate had been discontinued recently because of elevated transaminases. She presented to the emergency department with a headache, pain on eye movements, periocular swelling, and acute vision loss in her left eye. B scan ultrasound of the left eye confirmed a thickened posterior sclera with a positive T sign .
Exam
| OD | OS | |
|---|---|---|
| Visual acuity | 20/20 | Hand motion (HM) |
| Intraocular pressure (IOP) | 18 | 28 |
| Afferent pupillary defect (APD) | No | Yes |
| Lids | Normal | Edema, erythema |
| Sclera/conjunctiva | White and quiet | Diffuse injection |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | Deep and quiet | Deep and quiet |
| Iris | Unremarkable | Unremarkable |
| Lens | Clear | Clear |
| Anterior vitreous | Clear | Clear |
| Disc | Normal, 0.4 | 4+ edema ( Fig. 62.1 ) |
| Macula | Normal | Serous neurosensory retinal detachment, diffuse intraretinal hemorrhages ( Fig. 62.1 ) |
| Vessels | Normal | Extensive and severe, white-yellow perivenular sheathing throughout macula and retinal midperiphery ( Fig. 62.1 ) |
| Periphery | Normal | Vasculitis extending to midperiphery with smaller white centered hemorrhages peripherally ( Fig. 62.1 ) |
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