Publication Exclusive: Pregnant woman presents with floaters and decreased vision

A 32-year-old pregnant woman at 31 weeks’ gestational age was referred to the New England Eye Center for a 1-week history of floaters and decreased vision in the left eye. She complained of 1 day of photophobia and left eye pain.

Ocular history was unremarkable. Medical history included prior cesarean section, hepatitis C and spinal desmoid tumors resected and treated with doxorubicin. She had a history of intravenous drug use and stated the last episode was 8 months before presentation. She lived in a rural area with exposure to many animals including cats, dogs and horses and had removed ticks from her skin over the past year.

Examination

Initial exam showed a best corrected visual acuity of 20/20 in the right eye and 20/100 in the left eye. Pupils were equal and brisk with no evidence of an afferent pupillary defect. Confrontation visual fields and extraocular movements were full bilaterally. IOP was 8 mm Hg in the right eye and 6 mm Hg in the left eye.

Anterior segment exam of the right eye was normal. Slit lamp biomicroscopy of the left eye was significant for diffuse conjunctival injection with 4+ cell and 2+ flare in the anterior chamber. The cornea, iris and lens were all noted to be normal. Posterior examination of the left eye revealed 2+ anterior vitreous cell, multiple vitreous opacities and retinal lesions involving the macula. There were no peripheral lesions or evidence of vasculitis. Funduscopic exam of the right eye was normal. OCT confirmed the presence of vitreous debris and a pre-retinal infiltrate.

What is your diagnosis?

Unilateral panuveitis

The differential diagnosis for unilateral panuveitis is broad but can be categorized into infectious, inflammatory and neoplastic syndromes.

Infectious considerations include endogenous endophthalmitis, specifically bacterial or fungal, given the patient’s history of intravenous drug abuse. The clinical appearance was most consistent with fungal endophthalmitis given the “fluffy” vitreous opacities. Other infectious entities include syphilis, tuberculosis, toxoplasmosis, CMV retinitis, herpes simplex virus or herpes zoster virus. Syphilis and tuberculosis can present in varied forms and should always be considered in the differential of panuveitis. Toxoplasmosis, a commonly identified cause of posterior uveitis, is typically a unilateral granulomatous uveitis with retinitis adjacent to a chorioretinal scar. The retinal findings in our patient were not consistent with toxoplasmosis. CMV retinitis typically presents with retinal necrosis and hemorrhages, neither of which our patient demonstrated. While acute retinal necrosis, caused by herpes simplex and herpes zoster viruses, can present with panuveitis, areas of retinal necrosis and retinal vasculitis are usually appreciated on exam.

Sarcoidosis should always be considered in cases of panuveitis given its variable presentation. Primary intraocular lymphoma can present similarly to uveitis; however, these patients typically do not have pain, conjunctival injection or anterior chamber inflammation.

Click here to read the full publication exclusive, Grand Rounds at the New England Eye Center, published in Ocular Surgery News U.S. Edition, December 25, 2015.