History of Present Illness
A 58-year-old man complains of progressive decrease in vision in both eyes (OU) over the last month. His past medical history is notable for metastatic cutaneous melanoma. He dismissed his symptoms initially, but after his vision did not improve spontaneously—in fact, he thinks it probably worsened over that time—he presented to a local ophthalmologist who then referred him on an expedited basis to the uveitis service. The referral simply notes “inflammation” OU and notes a concern for “infection” because the patient is on “chemotherapy.”
Questions to Ask
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What cancer treatments have you been on in the past and what are you on currently?
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Has your course been complicated by any recent infections or hospitalizations?
He responds that he was first diagnosed with a cutaneous melanoma on his back 10 years ago.
He underwent local excision and was stable until a little under a year ago, when he was diagnosed with metastatic disease. He has metastases to his liver and lungs. His oncologist started him on the immunotherapeutic nivolumab, a programmed death-1 inhibitor (PD-1, a T-cell immune checkpoint) about 6 months ago, and he has responded very well to it. He has had no other complications or hospitalizations since his most recent diagnosis.
| OD | OS | |
|---|---|---|
| Vision | 20/40 | 20/30− |
| Intraocular pressure (IOP) | 30 | 28 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | Clear stroma, fine keratic precipitates (KP) | Clear, fine KP |
| Anterior chamber (AC): | 2+ white cells | 2+ white cells |
| 1+ flare | 1+ flare | |
| Iris: | Flat | Flat |
| Lens: | Clear | Clear |
| Anterior vitreous: | 2+ white cells | 2+ white cells |
| Dilated fundus examination (DFE): | See Fig. 58.1A | See Fig. 58.1B |
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