History of Present Illness
A 25-year-old woman with no past medical history and a long-standing history of myopia presents for the first time to the eye clinic complaining of distorted vision in her right eye (OD). She first noticed that her vision was a little blurry about a month ago, which also coincided with more floaters than she is used to. She had assumed that these symptoms were insignificant and would resolve, but then 2 weeks later she noticed a grayed-out area of vision paracentrally OD, so she decided to present to the eye clinic.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/40 | 20/20 |
| Intraocular pressure (IOP) | 18 | 19 |
| Sclera/conjunctiva | White and quiet | White and quiet |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | 2+ white cells | Deep and quiet |
| 1+ flare | ||
| Iris | Unremarkable | Unremarkable |
| Lens | Clear | Clear |
| Anterior vitreous | 2+ white cells | Clear |
| Nerve | Cup-to-disc (c/d) 0.1, peripapillary |
| atrophy | |
| Macula | Lacquer cracks |
| Vessels | Normal caliber and course |
| Periphery | Unremarkable |
Questions to Ask
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Have you noticed anything in the left eye (OS)?
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Have you had any recent illnesses or hospitalizations?
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Are you having or have you recently had any other symptoms in the rest of your body, such as joint pains, new rashes, breathing problems, problems with bowel movements, or oral or genital ulcers?
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Have you had any tick bites recently?
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Have you ever traveled outside the country?
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Have you had any trauma or surgery to the eye?
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Do you use injection drugs?
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Do you practice safe sex?
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What is your glasses prescription?
The patient answers no to the first seven questions. She has always used barrier protection during sex. She hands over her glasses, and the Rx is −9.00 +0.75×180 OD, −8.50 +0.50×145 OS.
Fluorescein angiography (FA) and optical coherence tomography (OCT) were pursued to further investigate the cause of metamorphopsia and subretinal hemorrhage ( Fig. 28.2 ).
Assessment
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Panuveitis with occult multifocal choroiditis (MFCPU) by angiography OD
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Choroidal neovascularization OD
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High myopia OU with secondary lacquer cracks
Differential Diagnosis
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Idiopathic
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Sarcoidosis
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Syphilis
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Less likely: tuberculosis, atypical Mycobacteria , subacute fungal infection
Working Diagnosis
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Noninfectious MFCPU, but rule out infectious causes before starting therapy.
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The patient has no risk factors for common infectious causes of multifocal choroiditis, nor is she immunosuppressed. Her young age, female gender, and myopic refraction are classic for idiopathic MFCPU.
Testing
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FA and OCT already performed, as noted earlier
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Indocyanine green (ICG) (not performed) is a superior test for identifying areas of choroiditis
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Check fluorescent treponemal antibody absorption (FTA-ABS), rapid plasma reagin (RPR), QuantiFERON or purified protein derivative (PPD), angiotensin-converting enzyme (ACE), lysozyme, and chest x-ray (CXR)
Management
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Start prednisone 60 mg by mouth (PO) daily once infectious laboratory tests are negative
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Prednisolone acetate 1% four times a day (QID) OD, cyclopentolate 1% twice a day (BID) OD
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Defer anti–vascular endothelial growth factor (VEGF) treatment for now, as new inflammatory choroidal neovascularization (CNV) will often respond to antiinflammatory therapy
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Follow up in 2 weeks
Follow-up
The patient has the appropriate diagnostic tests performed, all of which are negative. However, she does not return to the clinic as scheduled in 2 weeks, nor does she reschedule.
She returns 8 months later complaining of severe loss of vision OD. She admits that she never started the prednisone, as prescribed, and only used the eye drops intermittently. However, she is now very concerned about her vision ( Figs. 28.3 and 28.4 ).
