Transcript Folie 1 - Springer Static Content Server

Posterior Uveitis,
or?
Debra Goldstein, MD
Northwestern University
Chicago, IL
Ocular History
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78 yo old WM
History of sarcoid uveitis OD diagnosed 2007
New onset of foggy vision OD
Seen by retina surgeon, told had uveitis recurrence.
Dexamethasone intravitreal implant was
recommended.
As the patient lay draped and ready for injection,
he began to have second thoughts…
Presented back to the uveitis service
Past Ocular History
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Initially referred to the Uveitis Service 2007 with the diagnosis of
Primary Intraocular Lymphoma OD.
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On exam at that time:
 VA OD: 20/70,
OS: 20/20
 Conjunctival granulomas OU
 Granulomatous KP OD
 AC and vitreous cell OD
 CME OD
 2 small choroidal granulomas
 No retinitis
Past Ocular History
 Differential Diagnosis:
 Sarcoid, TB, Syphilis. PIOL much less likely
 Work up:
 ACE normal, lysozyme elevated
 FTA-Abs – NR
 QuantiFERON – neg
 CXR - lung nodule
 Biopsy – non caseating granulomas c/w sarcoidosis
Past Ocular History
Diagnosis
Granulomatous iridocyclitis,
choroidal granulomas, CME OD
secondary to Sarcoidosis
Past Ocular History
Short course topical steroids and posterior
subtenon triamcinolone injection
 Complete resolution of inflammation
 VA returned to 20/20
 Lost to follow up since 2009
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Interim history
 Diabetic,
hypertensive, obese
 No malignancy
 No systemic immunosuppressive therapy
May 2013: First Presentation
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BCVA 20/40 OD, 20/20 OS
Slit Lamp Exam:
 Small conjunctival granulomas OU
 OD:
 Almost confluent active greasy KP inferiorly
 2+ AC cell
 2+ AV cell, 1+ vitreous haze
 OS:
 Normal
Diagnosis and Treatment
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Necrotizing herpetic retinitis in an eye with
previous sarcoid uveitis
 VZV
 HSV
 CMV
AC tap –VZV, HSV and CMV PCR
Valtrex 2mg PO TID and topical Pred Forte
Course
Aqueous PCR
 98,400 copies of VZV
 All others negative
 Resolution of retinitis and haze
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8 days after treatment
with Valtrex 2g TID
2.5 month after treatment initiated
Summary
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78 yo relatively immunocompetent male
 Biopsy proven sarcoidosis
 History strictly unilateral sarcoid uveitis
 Presenting with vitritis after a period of
quiescence for nearly 7 years
Recurrence of sarcoid uveitis not responsible
for the second presentation
Discussion
 Unusual to have two diagnoses in one
eye…
 Is it possible that increased vascular
permeability from prior inflammation
resulted in increased risk of entry of
virus into retina?
Key Points
It is possible for one eye to have two or
more diagnoses
 The opposite of Occam's razor is ‘Hickam's
dictum: “A patient can have as many disease
as he or she pleases.”
 Remember: Not all uveitis is treated with
steroids
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