History of Present Illness
A 31-year-old healthy woman with no significant past medical history presents to the eye clinic for the first time complaining of progressively decreased vision over the last 2 weeks. She notes that it first started in the left eye (OS) with mild sensitivity to light, followed quickly by blurred vision. She noticed similar symptoms in the right eye (OD) a few days later. She brushed off her symptoms for the first few days, but they have been getting progressively worse.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/100 | 20/200 |
| Intraocular pressure (IOP) | 20 | 22 |
| Sclera/conjunctiva | 1+ injection | 1+ injection |
| Cornea | Clear stroma, mutton-fat keratic precipitates (KP) | Clear stroma, mutton-fat KP |
| Anterior chamber (AC) | 2+ white cells | 2+ white cells |
| 1+ flare | 1+ flare | |
| Iris | Unremarkable | Unremarkable |
| Lens | Clear | Clear |
| Anterior vitreous | 2+ white cells | 2+ white cells |
| Dilated fundus examination (DFE) | Fig. 54.1A | Fig. 54.1B |
Questions to Ask
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Have you ever suffered a serious injury to either eye or ever had intraocular surgery?
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Have you noticed any neck stiffness, changes in your hearing, or changes in the color of your skin or hair?
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Do you have any Native American or East Asian ancestry?
She has never had any serious trauma to either eye, nor has she had surgery. She has not noticed any neck stiffness or issues with her hearing, hair, or skin. She answers that one of her grandparents was of Cherokee descent.
Assessment
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Panuveitis with multifocal, large serous retinal detachments both eyes (OU)
Differential Diagnosis
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Vogt–Koyanagi–Harada (VKH) syndrome
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Sympathetic ophthalmia
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Less likely: posterior scleritis, systemic leukemia/lymphoma involving the eyes
Working Diagnosis
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VKH
Testing
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The presentation of bilateral, presumably granulomatous, panuveitis with nerve swelling and multiple funduscopically obvious serous detachments is consistent only with VKH (or simply Harada syndrome if there is no systemic involvement) or sympathetic ophthalmia. The absence of a history of penetrating trauma or surgery to the eye rules out sympathetic ophthalmia, leaving only VKH. Posterior scleritis characteristically has pain, which is absent here.
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The diagnosis should be confirmed with fluorescein angiography (FA) ( Fig. 54.2 ).
