History of present illness
An 84-year-old woman from India presented with blurred vision in the left eye (OS). She is asymptomatic in the right eye (OD). She is in overall good health with medically managed hypertension and low back pain. She is known to have a cystic mass in L1 reportedly stable for years. She is pseudophakic in both eyes (OU) after cataract surgery more than 21 years ago. She also has reportedly well-managed glaucoma and is status posttrabeculectomy OS.
Questions to ask
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When did you first notice the vision change?
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“Two weeks ago.”
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What associated symptoms are present? Any pain or light sensitivity? Any floaters?
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Patient noted that her vision was very blurry in the left eye and there was no pain, light sensitivity, or floaters.
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Any prior symptoms?
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None
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Is there any history of surgery or trauma to OS?
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Yes, trabeculectomy years ago for glaucoma in the left eye. The glaucoma has been well managed since then. No history of trauma.
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Any systemic symptoms? Fever, chills, weight loss, cough, or shortness of breath?
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Chronic low back pain
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Any family have a history of eye disease? Inflammatory disease?
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None
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Any recent travel?
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Yes, patient came to the United States from India 6 months ago to stay with her son.
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Any prior testing for tuberculosis (TB)?
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Yes, recently had a purified protein derivative (PPD) test, as required for immigration; it was negative.
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Did patient have the bacillus Calmette–Guérin (BCG) vaccine?
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Yes. Patient noted that everyone where she grew up got this vaccine.
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Ocular exam findings and imaging
Best-corrected visual acuity in OD was 20/50 and in OS was hand motion. Intraocular pressure OD was 22 mm Hg and OS was 2 mm Hg. Slit-lamp examination revealed a flat trabeculectomy bleb OS. Examination of the anterior chambers (ACs) revealed bilateral granulomatous keratic precipitates (KPs) with 4+ AC cell and both Koeppe and Busacca nodules of the iris OU. The anterior vitreous OD had 2+ cells with 2+ haze and OS had 3+ cells with 4+ haze. Fundus examination OD revealed multiple orange subretinal lesions in the posterior pole and a larger yellow-white choroidal nodule inferior to the optic disc in the midperiphery. OD also had mild optic disc edema and a shallow peripheral retinal detachment (RD) inferiorly. Fundus examination OS revealed a total bullous RD. No retinal breaks were noted on careful examination Fig. 37.1 .
Differential diagnosis
The differential can be broken down into infectious and noninfectious causes of granulomatous panuveitis (see, Algorithm 37.1 ). At the top of the infectious differential is TB; most other infections (except syphilis) are ruled out by the subacute (rather than hyperacute) presentation in an otherwise healthy patient. Ocular TB can affect all orbital and ocular tissues. When intraocular, TB typically manifests as a granulomatous panuveitis. Choroidal lesions may be small, known as tubercles, or large, referred to as tuberculomas. There may also be iris nodules, anterior and intermediate uveitis, and retinal vasculitis.
The most likely noninfectious etiology in this case is Vogt-Koyanagi-Harada disease, a granulomatous autoimmune panuveitis that often presents after a prodrome of tinnitus and meningitis. Ocular findings at onset include granulomatous KPs, ACs, and vitreous cells; an inflamed optic nerve (“cherry red” disc); and exudative retinal detachments (ERDs). Later, small or large choroidal nodules may be seen. Another granulomatous uveitis would be sarcoidosis, although this presentation was much more dramatic than is typically seen.
Certainly, malignancy can present with choroidal nodules, but one would not expect the bilateral granulomatous panuveitis presentation.
Working diagnosis
Bilateral painless granulomatous panuveitis with choroidal lesions OD, subretinal fluid (SRF) peripherally OD, and ERD OS in a patient from an endemic area, most likely tuberculous despite the negative PPD.
Algorithm 37.1 : General posterior uveitis differential diagnosis
