Immunology Case Report #1

Immunology Case Reports are posted as a service of the National Eye Institute's Laboratory of Immunology to encourage dialog and collaboration between clinicians and researchers with an interest in ocular immunology and immunopathology. Your medical opinions on this case are welcome will be published on this page.

Please send your comments to:

Chi-Chao Chan, M.D.
ccc@helix.nih.gov

Janine Smith, M.D.
jmas@box-j.nih.gov

Presenting Physician

Chris Walton, M.D.
Department of Ophthalmology
University of Tennessee Memphis
956 Court Avenue, Room D228
Memphis, TN 38163
(901) 448-5883
cwalton@mail.eye.utmem.edu

A 17-year-old male was referred with a one-week history of photophobia and decreased acuity in the left eye. He had been diagnosed with iritis and treated with topical prednisolone acetate for five days. Past medical history and review of systems was unremarkable except for a history of numerous tick bites not associated with a rash or other sequelae.

When first seen, visual acuity was 20/20 OU. Slit lamp examination revealed 3+ anterior chamber cells with pigment on the anterior lens capsule as well as 1-2+ vitreous cells and trace haze OS. Several small deep retinal/RPE lesions approximately 200µ in diameter were noted along the superotemporal vascular arcade OS. Fluorescein angiography revealed only faint staining of the lesions. Topical corticosteroids were continued every two hours.

Three weeks later, his visual acuity was 20/20-1 OS. Fine KP with 2+ anterior chamber cells and Koeppe nodules were noted. 2+ vitreous cells and trace haze were present. The previously noted fundus lesions were unchanged; however, several new lesions were noted nasally. Topical corticosteroids were continued at the same dosage.

Ten days later, he returned after developing a left peripheral facial nerve palsy. He had been seen by a pediatrician and a complete blood count, blood glucose, serum ACE, FTA-ABS, and Lyme titers were obtained. There was no change in his ophthalmologic exam at that time. The Lyme titer and FTA-ABS were subsequently reported as negative. The CBC, glucose, and serum ACE were within normal limits.

Two weeks later (seven weeks following the onset of symptoms), he complained of pain and redness in the right eye. Examination revealed a visual acuity of 20/25+2 OD and 20/25+1 OS. No pupillary abnormalities were noted. 4+ anterior chamber cells and 1+ flare with posterior synechiae were present OD. The left eye was quiet at that time. Several fundus lesions similar to those in the left eye were seen along the inferotemporal arcade in the right eye. The fundus lesions were unchanged in the left eye. Hourly topical corticosteroids were begun in the right eye.

After two weeks of hourly topical corticosteroids, there was no improvement in the right eye. During the next three weeks, he received two subtenon's injections of triamcinolone acetonide with subsequent improvement in the inflammation. There was no change in the fundus lesions following therapy.

Additional diagnostic work-up and differential diagnosis for this case.