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Posterior Uveitis, or?

Read the intriguing case of a 78-year-old male with recurrent sarcoid uveitis and subsequent herpetic retinitis, discussing diagnosis, treatment, and reflections on multiple ocular conditions.

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Posterior Uveitis, or?

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  1. Posterior Uveitis,or? Debra Goldstein, MD Northwestern University Chicago, IL

  2. Ocular History • 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

  3. Past Ocular History • Initially referred to the Uveitis Service 2007 with the diagnosis of Primary Intraocular Lymphoma OD. • 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

  4. 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

  5. Past Ocular HistoryDiagnosis Granulomatous iridocyclitis, choroidal granulomas, CME OD secondary to Sarcoidosis

  6. 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

  7. Interim history • Diabetic, hypertensive, obese • No malignancy • No systemic immunosuppressive therapy

  8. May 2013: First Presentation • 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

  9. Diagnosis and Treatment • 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

  10. Course • Aqueous PCR • 98,400 copies of VZV • All others negative • Resolution of retinitis and haze

  11. 8 days after treatment with Valtrex 2g TID 2.5 month after treatment initiated

  12. Summary • 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

  13. 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?

  14. 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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