1. Debra Goldstein, MD Northwestern University Chicago, IL
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 History Diagnosis
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

10. 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

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

12. 8 days after treatment with Valtrex 2g TID
2.5 month after treatment initiated

13. 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

14. 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?

15. 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