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

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

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

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

Interim history Diabetic, hypertensive, obese No malignancy No systemic immunosuppressive therapy

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

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

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

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

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

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