History of Present Illness
A 38-year-old man with a history of idiopathic recurrent anterior uveitis both eyes (OU) and no significant past medical history complains of blurred vision in his left eye (OS). He noticed some change about 2 or 3 weeks ago but did not think anything of it. It has been getting worse, and he says images look misshapen and smaller out of his left eye than out of the right. He has never experienced something like this before, and it is unlike his usual flares, which present with intense photophobia and mild blurring of vision.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/20 | 20/40+ |
| IOP | 12 | 14 |
| Sclera/conjunctiva | White and quiet | White and quiet |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | Deep and quiet | Deep and quiet |
| Iris | Unremarkable | Unremarkable |
| Lens | Clear | Clear |
| Anterior vitreous | Clear | 1+ old cells |
| Nerve: | Cup-to-disc (c/d) 0.2, pink, sharp | c/d 0.2, pink, sharp |
| Macula: | Normal | Blunted foveal reflex |
| Vessels: | Normal caliber and course | Normal caliber, sheathing temporally |
| Periphery: | Unremarkable | Unremarkable |
Questions to Ask
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Before being treated at this clinic, were you ever told you had swelling in the retina?
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Have you been treated with injections directly into the eye or around the eye in the past?
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Have there been any changes in your general health since you last came to the eye clinic?
The patient answers “no” to all questions.
Because of the suspicion of macular edema in the left eye, optical coherence tomography (OCT) and fluorescein angiography (FA) were performed ( Figs. 71.1 and 71.2 ).
Assessment
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Uveitic cystoid macular edema (CME) OS
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Active retinal vasculitis OU
Differential Diagnosis
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The patient has no significant past medical history and has had an extensive evaluation for infectious and inflammatory etiologies, including cytoplasmic antineutrophil cytoplasmic antibodies (cANCA) and perinuclear antineutrophil cytoplasmic antibodies (pANCA). It is reasonable to assume for now that the vasculitis is a manifestation of his idiopathic uveitis.
Working Diagnosis
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Idiopathic retinal vasculitis OU complicated by CME OS
Testing
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None
Management
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Prednisone 60 mg by mouth (PO) daily
Follow-up
Over the course of the following weeks, the vasculitis improves, cystoid macular edema resolves, and the patient’s vision returns to 20/20 OU. However, over the next 3 months, the prednisone dose cannot be reduced to below 15 mg PO daily without recurrence of active retinal vasculitis and CME OS.
Management
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Start immunomodulatory therapy. Methotrexate was initiated and titrated up to 20 mg PO every week.
Follow-up #2
After 4 months of methotrexate therapy, the prednisone dose has been reduced to 7.5 mg PO daily while the vasculitis remains inactive. However, the patient presents again with recurrent CME OS and vision has declined to 20/40 OS.
Management
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Intravitreal triamcinolone 2 mg/0.05 cc OS
Follow-up #3
The patient returns a month later. He is pleased and reports he is seeing much better. His vision has improved to 20/20 OS, but intraocular pressure (IOP) is 40 ( Fig. 71.3 ).
