History of Present Illness
A 33-year-old woman with no significant past medical history presents to the eye clinic complaining of slowly progressive decreased vision over the past 6 months. She notes that it first started in her left eye (OS) with mild sensitivity to light, followed by blurred vision. She has not noticed similar symptoms in her right eye (OD). Because her vision has gotten progressively worse, she decided to see an eye doctor. She has worn glasses since early childhood and knows that she is myopic.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/20 | 20/400 |
| Intraocular pressure (IOP) | 13 | 10 |
| Sclera/conjunctiva | Within normal limits (WNL) | Episcleral injection with mild conjunctival hyperemia |
| Cornea | WNL | Few nongranulomatous (NG) KP |
| Anterior chamber (AC) | WNL | 1+ cell, 1+ flare |
| Iris | WNL | No posterior synechiae |
| Lens | Clear | Clear |
| Vitreous cavity | WNL | 1+ vitreous cells |
| Retina/optic nerve | Multiple small (50–250 μ), round, discrete, yellowish lesions with indistinct borders ( Fig. 36.1 ) |
Questions to Ask
- •
Do you have any other ocular complaints or symptoms?
- •
How nearsighted are you?
- •
Have you had any recent viral illnesses within the past year?
She does notice multiple scotomas, occasional photopsias and floaters in her OS, and has no problem with her OD. Her myopia has not progressed, and she is about −4.00 D both eyes (OU). No major illnesses in the past year, including viral infections.
Assessment
- •
White dot syndrome (WDS), OS, with mild panuveitis and multifocal choroiditis (MFC)
Differential Diagnosis
- •
Multifocal choroiditis with panuveitis (MFC-PU)
- •
Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)
- •
Sarcoidosis
- •
Punctate outer retinal toxoplasmosis
- •
Infectious retinitis (tuberculosis [TB], syphilis)
- •
Presumed ocular histoplasmosis syndrome
- •
Punctate inner choroidopathy (PIC)
- •
Birdshot chorioretinopathy
Working Diagnosis
- •
MFC-PU, OS
Testing
- •
The presentation of unilateral MFC-PU has an extensive differential diagnosis, and the routine laboratory tests to exclude infection and sarcoidosis were performed. The entities of WDS can be distinguished by fundus appearance and natural history.
- •
Fundus fluorescein angiography (FFA): ( Fig. 36.2 , left panel)
