History of Present Illness
A 33-year-old farmer from a local village in India presents for the first time to the local eye clinic complaining of blurry vision in his left eye (OS). Review of systems was positive for fever 1 month before the onset of his eye problem.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/20 | Hand motion |
| Intraocular pressure | 17 mm Hg | 17 mm Hg |
| Sclera/conjunctiva | White | Mild circumcorneal congestion |
| Cornea | White | Diffuse nongranulomatous keratic precipitates |
| Anterior chamber | Deep and quite | 4+ cells/flare, see Fig. 60.1 |
| Iris | Normal color and pattern | Normal color and pattern |
| Lens | Clear | Pearly white, mature cataract |
| Anterior vitreous | Unremarkable | Poor view due to cataract |
A B scan OS was performed, which showed moderate vitreous opacities and attached retina.
Questions to Ask
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Have you had any injury in your left eye?
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When was the last time your vision was close to normal?
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Have you had any similar eye problems in the past?
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Do you have close contact with cattle, pets, or other animals, such as rat bites?
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Do you have a history of fever, jaundice, or myalgias?
His vision was close to normal just a few weeks ago. He further responds that, as a farmer, he has had close association with cattle and started to have a fever after his cattle became febrile while having an abortion. He has never had anything like this before, and he denied any rat bites. He has had fever lasting for 10 days with severe myalgia and jaundice.
Assessment
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Acute, nongranulomatous, hypopyon anterior uveitis and intermediate uveitis
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Complex, rapidly progressive, white cataract OS, associated with uveitis
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Sudden-onset fever, myalgia, and jaundice suggesting systemic infection, possibly zoonotic
Differential Diagnosis
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Most likely: Leptospiral uveitis
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Traumatic cataract with lens-related uveitis
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Behçet anterior and intermediate
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Endogenous fungal endophthalmitis
Working Diagnosis
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Hypopyon uveitis OS, most likely leptospiral.
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The patient is from an area that is endemic with leptospirosis, he works in an occupation at high risk for exposure to Leptospira , and he has systemic symptoms consistent with the diagnosis. The rapid onset of cataract is also highly suggestive.
Testing
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Complete blood count (CBC) with differential
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Purified protein derivative (PPD)
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Rapid plasma reagin (RPR), fluorescent treponemal antibody absorption (FTA-ABS)
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Leptospirosis micro-agglutination test
Management
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Await results of testing
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Start prednisolone acetate 1% every hour (q1h) OS
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Follow up in 2 days
Follow-up
The patient follows up 2 days later. His symptoms and examination are stable. Micro-agglutination test returned positive 1:1200 for Leptospirosis icterohaemorragica .
Management
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Start doxycycline 100 mg by mouth (PO) twice a day (BID)
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Start prednisone 60 mg PO daily
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Continue prednisolone acetate 1% q1h OS
Further Follow-up
The patient’s inflammation improved rapidly, and oral and topical corticosteroids were slowly tapered starting 2 weeks after presentation. Vision remained in the count fingers range due to mature cataract OS. After 3 months of quiescence, the patient underwent cataract extraction with intraocular lens implantation OS and ultimately regained 20/20 vision after surgery.
Key Points
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Leptospiral uveitis is one of the most common causes of hypopyon uveitis in leptospiral-endemic areas.
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Other clinical signs are retinal vasculitis, vitreous membranes, and disc hyperemia. Early onset, rapid progression, and spontaneous absorption of cataractous lens are unique features in this uveitis; however, it is seen only in 1% of leptospiral uveitis.
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Dense vitreous inflammation with the formation of veil-like membranous vitreous opacities is a pathognomonic sign seen in the posterior segment ( Fig. 60.2 ).
