1. Unexplained Fever in Pregnancy
Dr. Rathinam Sivakumar
Uveitis Services
Consultant, Uveitis Service
Aravind Eye Hospital
Madurai
India

2. General History 26 year old lady, engineer sudden painless loss of
vision in BE since 3 days
fever and cough for two months
cough was associated with haemoptysis
amenorrhea of 3 months,hospitalized and treated with ATT at general gynecology department.
Then referred to our hospital

3. EXAMINATION VA DISTANCE NEAR 3/60 NIG or PH N36 at 25cm 3/60 NIG or PH
ANTERIOR SEGMENT
CORNEA
CLEAR
ANT.CHAMBER
ND ,QUIET
IRIS
NCP
PUPIL REACTION
ILLSUSTAINED
LENS
EOM
FULL
EXAMINATION

4. BE
MEDIA
CLEAR; NO VIT HAZE
DISC
DISC ODEMA
VESSELS
SHEATHING OF VESSELS;ACTIVE VASCULITIS
MACULA
DULL FR
BACKGROUND RETINA
MULTIPLE COTTON WOOL SPOTS; MULTIPLE SPLINTER HAGE

5. Initial Diagnosis of Ocular Disease
Retinal vascular occlusive disease of unknown origin

6. Investigations Hb: 7g% WBC: 8,600 cells/cumm, platelets: 2 lakhs/cumm
ESR: 28mm at ½ hr, 55mm at 1 hr
Bleeding & Clotting Time : Normal
CRP: 22.9mg/ lit (N: up to 6 mg/l)
serum amylase: 91 IU/L (0 to 85 IU/L)
serum rheumatoid factor: 3.14 IU/ml (0 to 30)
plasma fibrinogen: 182 mg%
BL.glucose; sr creatinine; blood urea: WNL
PS: MICROCYTIC HYPOCHROMIC ANEMIA;
NEGATIVE FOR MALARIAL PARASITE
urine analysis: trace albumin

7. Differential Diagnosis
Adamantiades – Behcet´s Disease
Polyarteriitis nodosa
Takayasu disease
Wegeners granulomatosis
syphilis
systemic lupus erythematosus

8. History Review h/o hair loss h/o malar rash occasional joint pains
no h/o oral or genital ulcers
no h/o headache
no h/o DM or HTN in self or family

9. Diagnosis
SLE Retinopathy

10. Immediate Treatment
intravitreal triamcinolone acetate 0.1ml was given in BE as a first possible ocular treatment
as the patient was pregnant, she was referred to the Rheumatologist for systemic treatment

11. Investigation Rheumatologist for further invest.:
ANA: 9.2mg% (0.9 to 1.4mg%)
Anti Ds DNA; C3, C4; positive
Renal Function Test : WNL
Liver Function Test : WNL

12. Therapy all drugs have to be safe in pregnancy prednisolone 40 mg
ecosprin 75mg
calcium supplement
blood transfusion 1 pint
Counseled for medical termination of pregnancy.

13. Therapy – Follow-up medical termination of pregnancy was carried out.
IV cyclophosphamide first cycle
pulse methylprednisolone 1gm 3 days and maintained of
oral prednisolone 1mg/kg body wt.

14. Persistent vasculitis and progressive cotton wool spots
Follow up – After 1 Week
BE disc pallor and macular odema

15. Follow-up – After 1 MonthOD
no glaucomatous disc damage OU
resolved macular edema
no active vasculitis

16. Follow-up – After 1 MonthRE LE
Vision DISTANCE
NEAR
2/60
6/60 PH 6/18P (Untreated with TCA)
N 12 at 33 cm
IOP (mm Hg) 30 12

17. Therapy Revision for OD
Mycophenolate mofetil 1500mg /day
Prednisolone 20mg /day
Brimonidine 0.2% and
Timoptol 0.5%

18. Patient shifted her residence and got lost for follow up for 6 months

19. Follow-up – After 6 monthsOD
Extensive vascular occlusion
resolved macular edema
Advised FFA

20. SEVERE VASCULAR OCCLUSION WITH
MACULAR ISCHEMIA

21. NVD on the optic disc

22. Therapy updated
PRP in 3 sitings for the OS
after discussion with rheumatologists:
Trental as vasodilatator
400mg BD 15 days

23. Follow-up – After 7 months
presented with sudden onset defective vision since two days in OS

24. Follow-up – Ocular Examination
VISION
½ /60
HAND MOVEMENTS
CORNEA
CLEAR AC
SHALLOW ND
PUPIL
5mm FIXED
3mm SLUGGISH
lRIS
ECTROPION UVEA; NVI;PAS
NCP
LENS
PSCC
IOP 42 12
FUNDUS
CDR:0.8, inf NRR thinning NVE;
Media hazy
DISPERSED VH
FOLLOW UP ON JUNE,14TH 2010

25. Ocular Examination pale optic disc sclerosed vessels CWS
premacular hemorrhage
Pars PlanaVitrectomy with C3F8 under GVP

26. Treatment
PPV+C3F8 under guarded visual prognosis

27. Follow-up – After 8 monthsRE LE
VISION
1/60
6/12
IOP (mmHg) 36 15
Treatment was continued with immummunosuppressives and topical Dorzolamide 2% for the OD

28. Follow-up – After 9 monthsRE LE
VISION
1/60
6/9p
IOP(mm Hg) 18 10

29. Treatment
diode cyclophotocoagulation in OD
vitreous lavage in OS
she failed to follow-up.

30. Discussion autoimmune, non-organ specific connective tissue disorder
20% have ocular involvement
90% are women, mostly of child bearing age
all age groups and both genders affected
ocular activity may occur independent of systemic activity
Lupus retinopathy is an imp marker of disease activity
ocular inflammatory lesions may precede extraocular manifestation by several months

31. Conclusion
Although ocular involvement is benign, potentially blinding complications may occur.
Lupus retinopathy and neuro-ophthalmic involvement suggest systemic activity, therefore referral to a RHEUMATOLOGIST for management is mandatory.
Early diagnosis and timely institution of systemic therapy may minimize morbidity and mortality.