Topic outline

  • Grand Rounds

    A patient presented from the Bahamas with 5-month history of redness, worsening eye pain, and 5 days of decreasing vision with enlarging “red spots” bilaterally. There was no past ocular history. Past medical history notable for asthma, and previously treated Chlamydia. Upon presentation, visual acuity was count fingers bilaterally. IOP was 10mmHg and 19mmHg, in the right and left eye. Slit lamp examination disclosed 4+ scleral injection, haze, bilateral fatty KP, and a hypopyon in both anterior chambers. The right eye demonstrated a 1.5x1.5mm Seidel-positive nasal area of uveal prolapse. Similarly, the left eye demonstrated a 0.5mmx0.5mm Seidel-negative inferior area of uveal prolapse. B-Scan demonstrated diffuse bilateral thickening of the choroids. The patient had cyanoacrylate and BCL in each eye and started on fluoroquinolone, prednisolone, and atropine drops. Subsequently admitted, and started broad-spectrum IV antibiotics and IV corticosteroids. CXR demonstrated a small left-sided pleural effusion, without pulmonary pathology. CT Face showed bilateral circumferential globe thickening. On HD2, the hypopyons resolved. On HD3, MRI Brain and Orbits demonstrated bilateral uveitic infiltration of proximal optic nerve sheaths. Notably, QuantiFERON was positive, raising concerns for tuberculosis. All other rheumatologic/ infectious workup was negative. On HD5, the patient was started on RIPE and pyridoxine. On HD6, the patient completed a 5-day course of IV Solumedrol, and was discharged on oral Prednisone, amoxicillin/ clavulanate, and sulfamethoxazole/trimethoprim prophylaxis, plus RIPE and eyedrops. At follow-up, the VA was unchanged, and all meds were continued. Subsequently lost to follow-up. The patient eventually returned and it was found no drops or oral medications had been continued. The right eye was Seidel-positive and had glue/ BCL placement. All medications restarted. Remarkably, left VA had improved to 20/50. Subsequently lost to follow-up. Exam and VA were found to be stable at next visit. Steroid taper was initiated and cycloplegia/antibiotic drops discontinued.

    Presentation Date: 12/09/2021
    Issue Date: 01/07/2022