206 - what the fruitcake - asorn.org · 6 iofb fungal hyphae and yeast moral of the story the...

UVEITIS“What the…………Fruitcake?!!!!”

E. Mitchel Opremcak, MD

The Retina Group

The Eye Center of Columbus

Professor of Ophthalmology and Visual Sciences

Ohio State University

Columbus, Ohio

UVEITIS“What the…………Fruitcake?!!!!”

E. Mitchel Opremcak, MD

I have no financial interests or relationships to disclose

Patient: GW 54 year old WM

CC: Painful LOV OD

HOPI: 9/12/14 One month Hx

severe pain and LOV OD

VA 20/200 and 3+ cell in vitreous

Acute panuveitis and W/U recommended

Lost to F/U and treated elsewhere with STK and prednisone for 6 months

2/17/15 Consult EMO

PMHx: DM (HA1c 17)

Meds: Lantus

ROS: Confused

Presumed Dx? “Severe idiopathic”

uveitis?

Ocular Exam - GW

VA OD: LP

VA OS: 20/25

SLE OD: Hyperemia, hypopyon, PS, Cataract

SLE OS: WNL

FE OD: No view

FE OS: WNL

Labs: ?

Ocular Exam - GW

VA OD: LP

VA OS: 20/25

SLE OD: Hyperemia, hypopyon, PS, Cataract

SLE OS: WNL

FE OD: No view

FE OS: WNL

Labs: B scan with vitreous

opacities

Choroidal thickening

Ocular Exam - GW

opacities

HOPI: Back to HOPI “It began after going

ginseng hunting in the woods.”

Ocular Exam - GW

opacities

I asked if he got hit with a branch and he denied it.

Ocular Exam - GW

opacities

His wife said that his friends saw him “get hit in the face real good.”

Ocular Exam - GW

opacities

His wife said that his friends saw him “get hit in the face real good.”

Dx: Endophthalmitis from an organic IOFB

7mm IOFB No CNS lesions

2/18/15 Diagnostic vitrectomy with IO Amphotercin

Heavy growth Candida albicans3/12/15 VA OD NLP

Enucleation

IOFB Fungal hyphae and yeast

Moral of the Story

The importance of taking a good HOPI

Do not “tough it out” if you poke yourself in the eye with a stick

If you have on a scale a 10/10 eye pain for 6 months with severe LOV…seek help!

Patient: CB 62 year old BM

CC: Decreased VA OU

HOPI: 2/6/15 Two year Hx

decreased VA and “many mistakes driving”

PMHx: HBP and HIV/AIDS

Meds: Lisinopril, Atripla

ROS: Neg

PE: WNL

Presumed Dx? CMV Retinitis?

Ocular Exam - CB

VA OD: 20/25

VA OS: 20/25

SLE OD: WNL

SLE OS: WNL

FE OD: Disc edema and CWS

FE OS: Disc edema and CWS

Labs: ?

Ocular Exam - CB

VA OD: 20/25

VA OS: 20/25

SLE OD: WNL

SLE OS: WNL

FA: Disc edema OU

Labs: ?

Ocular Exam - CB

VA OD: 20/25

VA OS: 20/25

SLE OD: WNL

SLE OS: WNL

FA: Disc edema OU

Labs: BP Normal

Left Homonomous Hemianopia

MRI - CB

6x7x8 cm Hemangiopericytoma

2 months s/p surgical resection

Moral of the Story

CWS around the optic nerve are worrisome

Papilledema is more worrisome

Visual fields and MRI are helpful

“It might be a tuma”

Patient: BC 65 year old WF

CC: Decreased VA OU

HOPI: 6/02 Red and pain OU

7/02 and 8/02 CE IOL OU

9/02 Retinal detachments

PMHx: IDDM

Meds: Humulin, Warfarin

ROS: HA

PE: WNL

Presumed Dx? Retinal detachments

following CE IOL?

Ocular Exam - BC

VA OD: 20/200

VA OS: CF 2 Ft

SLE OD: PC IOL and 1+ Vit Cell

SLE OS: PC IOL and 1+ Vit Cell

FE OD: Inf RD

FE OS: Inf RD

Labs: Mild anemia

Ocular Exam - BC

What the………….!

Clinical Course - BC

Bilateral RD

Bilateral Vitritis

Bilateral RD

Bilateral Vitritis

Vitiligo and poliosis

High end hearing loss

JDMG consult

Bilateral Exudative RD

Bilateral Uveitis

Vitiligo and poliosis

High end hearing loss

JDMG consult

VKH and AngioidStreaks

STK and return of 20/25 VA 9/08

Ocular Exam - BC

Angioid Streaks and VKH

VKH Syndrome

940-1010 Ali-ibn-Isa described uveitis with poliosis 1906 Vogt published first case 1926 Harada described a posterior uveitis

with exudative RD associated poliosis and pleocytosis in the spinal fluid 1929 Koyanagi described 6 cases of

iridocyclitis associated with poliosis, vitiligo, and added dysacusia and alopecia 1939 Babel called it V-K-H Syndrome

Histopathology

Granulomatouspanuveitis

Diffuse nodular lesions of epitheliod cells surrounded by lymphocytes and plasma cells

No sparing of choriocapillaris

More scarring

VKH Stages

Prodrome

Meningeal Phase

Ophthalmic Phase

Convalescent Phase

VKH Stages

Prodrome

Meningeal Phase

Ophthalmic Phase

Convalescent Phase

Autoimmune disease toward pigmented cells

Vitiligo

Criteria for VKH

1 – No trauma history

2 – No laboratory evidence for another disease

3 – Bilateral ocular disease

Early manifestations – diffuse choroiditis with RD

Late manifestations – depigmentation or pig clumping

4 – Neurologic/Auditory findings

Menigismus, HA/NA, Tinnitius, Vertigo, CSF pleocytosis

5 – Cutaneous findings

Alopecia, Poliosis or Vitiligo

Patient: RL 50 year old BF

CC: Decreased VA OS>OD

HOPI: 2 months blurred VA OU

PMHx: 20 year HxIDDM with poor control

Meds: Lantus

ROS: WNL

PE: WNL

Presumed Dx? Unresponsive PDR?

Ocular Exam - RL

VA OD: 20/25

VA OS: 20/70

SLE OD: WNL

SLE OS: WNL

FE OD: PDR

FE OS: PDR and CSDME

Labs: None

Ocular Exam - RL

4/19/10

Clinical Course - RL

OD: 4/10 PRP

4/11 PRP

8/11 PRP

10/11 PRP

OS: 4/11 Avastin

4/10 PRP

7/10 Focal

8/11 PRP

10/11 PRP

Clinical Course - RL “Unresponsive ”

10/21/11 What the…………….?

Clinical Course - RL “Unresponsive”

10/21/11

Vasculitis with capillary nonperfusion

10/21/11

Labs ESR 72

Lysozyme 27

Chest CT –mediastinallymphadenopathy

10/21/11

Labs ESR 72

Lysozyme 27

Chest CT –mediastinallymphadenopathy

Sarcoidosis with DM

Sarcoidosis

SarcoidosisRx – STK and MTX

Patient: MM 35 year old WF

CC: Sudden decrease VA OD

HOPI: 2/09 High fever

Severe HA

Sudden LOV

PMHx: N/A

Meds: None

ROS: N/A

PE: N/A

Presumed Dx? White Dot

Syndrome?

Ocular Exam - MM

VA OD: 5/09 20/400

Color desaturation

VA OS: 20/20

SLE OD: WNL

SLE OS: WNL

FE OD: White dots

Optic nerve palor

Macular exudates

FE OS: WNL

Labs: ?What the………..?

White Dot Syndrome

Ocular Exam - MM

VA OD: 5/09 20/400

Color desaturation

VA OS: 20/20

SLE OD: WNL

SLE OS: WNL

FE OD:

FE OS: WNL

Labs: ?

Ocular Exam - MM

VA OD: 5/09 20/400

Color desaturation

VA OS: 20/20

SLE OD: WNL

SLE OS: WNL

FE OD:

FE OS: WNL

Labs: B. henselae IgM 1:400

B. henselae IgG >1:2560

Clinical Course - MM

Doxycyline 100 mg PO BID

No improvement of VA

Diagnosis Cat Scratch Disease

American college of physicians web site

Cat Scratch Disease

Gram negative bacillus – Bartonella heselae

2000 BC – A 4000 year old molar had Bartonella

Parinaud (1889) – “Granulomatous conjunctivitis and lymph nodes following animal exposure”

1983 – Isolation of the bacillus

Patient: LB 23 year old WF

CC: Decreased vision OS

HOPI: SLOV 3/27/12

PMHx: N/A

Meds: None

ROS: N/A

PE: N/A

Presumed Dx?Retinal detachment

Ocular Exam - LB

VA OD: 20/20

VA OS: 20/400

SLE OD: WNL

SLE OS: Mild cell

FE OD: WNL

FE OS:

Ocular Exam - LB

Multiple Evanescent Whit Dot Syndrome - MEWDS

Unilateral (80%)

Young (26 years)

Females

Granular macula

Evanescent white dots

Mild vitritis

“Prolonged enlargement of the blind spot”

MEWDS – “Granular Macula”

MEWDS – “Wreath Sign”

Patient: CM 41 year old WM

CC: 10/10 None

HOPI: N/A

PMHx: N/A

Meds: None

ROS: N/A

PE: N/A

Presumed Dx? IRVAN - Idiopathic

retinal vasculitis, aneurysm and neuroretinitis?

Ocular Exam - CM

VA OD: 20/20

VA OS: 20/20

SLE OD: WNL

SLE OS: WNL

FE OD: Nasal cystic exudation

Subretinal cholesterol

FE OS: WNL

Labs: ?

Clinical Course - CM

What the……………………?

Ocular Exam - CM

VA OD: 20/20

VA OS: 20/20

SLE OD: WNL

SLE OS: WNL

FE OD: Nasal cystic exudation

Subretinal cholesterol

FE OS: WNL

Labs: FA

MRI (brainstem, cerebellum and brain)

Conservative observation

1/3/11 No change

4/25/11 No change

10/10/11 New loss of peripheral

vision

Avastin #1

11/21/11 Less SRF

Avastin #2

Diagnosis Juxtapapillary

capillary hemangioblastoma

Von Hippel Lindau

Autosomal dominant

Lost to F/U

Patient: KJ 36 year old WF

CC: Decreased vision OD for several days

HOPI: No pain or redness

PMHx: Negative

Meds: None

ROS: Negative

PE: WNL

Presumed Dx? “Choroiditis?”

Ocular Exam - KJ

VA OD: 20/50

VA OS: 20/20

SLE OD: WNL

SLE OS: WNL

FE OD: WNL

FE OS: White subretinal lesion

Retinal hemorrhage

Labs: Negative

Clinical Course - KJ

7/1/08

7/29/08

10/21/08

11/18/10

7/1/08 - Observe

7/29/08 – Prednisone

10/21/08 – CNV and STK

11/18/08 – CNV and Avastin

Diagnosis - ?

7/1/08 - Observe

Diagnosis – “Two optic nerve syndrome?”

7/1/08 - Observe

Diagnosis – UnifocalHelioid Choroiditis

Unifocal Helioid Choroiditis

“Sun-like”

Solitary, 1 DD, elevated, yellow-white choroiditis

Overlying subretinalfluid (heme)

Minimal cells

No systemic disease

Hong PD, Jampol LM . Arch Ophth 115,1007,1997

Patient: JG 19 year old WM

CC: Blurred VA and pain OD

HOPI: LOV for one month

PMHx: Pneumonia 2006 and colon polyp

Meds: PF 1% q1h

ROS: HA, sinus, genital ulcers, “never IV drugs but all others”

PE: Rash on left hand

SHx: House arrest and in jail 10/11

Presumed Dx? Vitritis

Ocular Exam - JG

VA OD: 20/100

VA OS: 20/20

SLE OD: Limbal flush, 1+ KP and 3+ Vit Cell

SLE OS: WNL

FE OD: Multiple foci retinitis

FE OS: WNL

Labs: ?

Ocular Exam - JG

VA OD: 20/200

VA OS: 20/20

SLE OD: Limbal flush, 1+ KP and 3+ Vit Cell

SLE OS: WNL

FE OD: Multiple foci retinitis

FE OS: WNL

Labs: WNL!

Clinical Course - JG

Suspected IV drug use

Initial started on Bactrimand Prednisone

One week later worse VA to 20/200

Worsening vitritis

Diagnostic vitrectomywith ceftazidime and vancomycin.

Worsening vitritis

Diagnostic vitrectomyMERSA

Skin rashes and abcess, MERSA in jail, abdominal pain

What the………………….?

Endogenous Endophthalmitis

“My puppy bites my left hand!”

Have you ever used IV drugs?

“I use to do IV drugs.”

When was the last time you used?

Yesterday!

Exogenous vs Endogenous Endophthalmitis

Patient: AS 19 year old AS

CC: No complaints

HOPI: REE Had a vit tap negative

10 days on prednisone and Bactrim

PMHx: WNL

Meds: None

ROS: WNL Denied IV drug abuse

PE: WNL

Presumed Dx? “Do not know what

this is.”

Ocular Exam - AS

VA OD: 20/20

VA OS: HM

SLE OD: WNL

SLE OS: WNL

FE OD: WNL

FE OS: 1+ cells

Ocular Exam - AS

What the……………………?

Ocular Exam - AS

Clinical Course - AS

12/22/11 Labs

Prednisone pulse

Add Doxycycline

1/6/12 Did not get

labs…”Car broke down.”

Still HM OS

2+ cells in vit

12/22/11 Labs

Prednisone pulse

Doxycycline

1/6/12 Did not get

Still HM OS

2+ cells in vit

1/11/12 Diagnostic vit

12/22/11 Labs

Prednisone pulse

Doxycycline

1/6/12 Did not get

Still HM OS

2+ cells in vit

Culture – Neg

Cytology – Neg

PCR – Neg CMV

Toxoplasmosis

What the………!

12/22/11 Labs

Prednisone pulse

Doxycycline

1/6/12 Did not get

Still HM OS

2+ cells in vit

Culture – Neg

Cytology – Neg

PCR – Neg CMV

Toxoplasmosis

Labs – ToxocaraELISA 2.27

1/12/12 POD1

1/19/12 2/2/12

3/1/12

Falciform fold

Toxocara

11/3/11 1/10/12

Toxocara

Eosinophilic Granuloma

Toxocara Falciform Fold

Patient: SHT 11 year old WF

CC: Decreased VA OS

HOPI: 4 week history

PMHx: WNL

Meds: None

ROS: WNL

PE: WNL

Presumed Dx? “Multifocal retinitis”

Ocular Exam - SHT

VA OD: 20/20

VA OS: 20/40

SLE OD: WNL

SLE OS: WNL

FE OD: WNL

FE OS: Multifocal retinitis

Labs: WNL

Ocular Exam - SHT

6/9/89 What the………………?

Ocular Exam - SHT

6/9/89 DUSN - Raccoon Ascarid

Clinical Course - SHT

Laser Photocoagulation

Clinical Course - SHT

Unilateral “Wipe Out Syndrome”

Patient: RF 48 year old WM

CC: Decreased VA OU

HOPI: 4/03 1 month Hx

PMHx: IDDM 12 years

HCV (1 year) on IFN (5 months)

Meds: Insulin and IFN

ROS: WNL

PE: WNL

Presumed Dx? CRVO

Ocular Exam - RF

VA OD: CF 3 Ft

VA OS: 20/60

SLE OD: WNL

SLE OS: WNL

FE OD: Retinal Heme

FE OS: Retinal Heme

Labs: None

Clinical Course - RF

What the………………………….?

What Rx?

Interferon Toxicity

D/C Interferon

1/29/08 VA OD: 20/400

VA OS: 20/60

Patient: CH 42 year old BF

CC: Bilateral ocular pain and redness

HOPI: 9/05 Pain and red OU

Rx Prednisone

1/06 Rheum MTX

5/06 Continued pain

PMHx: 60 pound weight gain

New DM and HBP

Meds: Pred, MTX, PF

ROS: Hair loss

PE: Cushings

Presumed Dx? Scleritis OU

Ocular Exam - CH

VA OD: 20/40

VA OS: 20/20

SLE OD: Diffuse Ant Scleritis

SLE OS: Diffuse Ant Scleritis

FE OD: WNL

FE OS: WNL

Labs: All WNL

Ocular Exam - CH

Clinical Course - CH

5/06 STK OU

Complex course and medically unresponsive

Additional W/U neg

5/06 STK OU

Additional W/U neg

7/06 Scleral BiospyCSF

Ocular Wegener’s Granulomatosis

Now cANCA +

IV cytoxan

11/06 Lung lesions

Bx positive

12/06 Oral Prednisone

IV Cytoxan

5/06 STK OU

Additional W/U neg

7/06 Scleral BiospyCSF

Ocular Wegener’s Granulomatosis

Now cANCA +

IV cytoxan

11/06 Lung lesions

Bx positive

12/06 Oral Prednisone

IV Cytoxan

New ocular pain and decreased VA OS

What the…………………?

Change Rx Prednisone

Imuran

Cellcept

1/12 Recurrent anterior

and posterior

Pred pulse

Wegener’s Granulomatosis

GPA – Granulomatosis with Polyangiitis

Patient: CS 68 year old WF

CC: Blurred VA OU

HOPI: One year Hx of blurred VA

PMHx: SLE “All her life”

RA “Since young”

Meds: Prednisone “All life”

Plaquenil 200mg BID 15 years

ROS: Many

PE: RA

Presumed Dx? RA

Ocular Exam - CS

VA OD: 20/25

VA OS: 20/25

SLE OD: PC IOL

SLE OS: PC IOL

FE OD: Pig changes

FE OS: Pig changes

Labs: N/A

Ocular Exam - CS

VA OD: 20/25

VA OS: 20/25

Color VA: 2/25 plates

SLE OD: PC IOL

SLE OS: PC IOL

FE OD: Pig changes

FE OS: Pig changes

Labs: N/A

OCT: Atrophic

Normal OCT – IS-OS Line

Clinical Course - CS

New Screening Guidelines for Plaquenil Toxicity

Hydroxychloroquine (Plaquenil) 200 mg PO BID

7 years = 1000 grams

1-7.5% Risk for macular toxicity (0.1%)

Baseline exam

Yearly after 5 years

New Recommendations VA, Color, FP and FA

VF 10-2

One of these three tests OCT (Loss of inner segment/outer segment line)

Hydroxychloroquine and the Retina

18,0511 RA/SLE patients on hydroxychloroquine 1,409 at high risk

50% lack a baseline exam

28% lacked regular eye visits

6% had no visits to eye care

35% had no diagnostic testing for toxicity

Nika N, Blachley TS, Edwards, P, et al. Regular examinations for toxic maculopathy in long-term chloroquine or hydroxychloquine users. JAMA Ophthalmol 2014;132(10):1199-1208

Melles RB and Marmor MF. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol. 2014;132(12):1453-1460

Patient: AS 68 year old Nepalese M

CC: VA loss and pain OD

HOPI: 2 year Hx pain and vision

loss OD

CE IOL OU

Post op RD OD

PMHx: HBP

Meds: None

ROS: WNL

PE: WNL

Presumed Dx? RD OD

Ocular Exam - AS

VA OD: 20/400

VA OS: 20/20

SLE OD: PC IOL

SLE OS: PC IOL

FE OD: ?

FE OS: WNL

Labs: WNL

Vitreous Cyst

B scan

Cysticercosis

Tapeworm

Taenia solium

VA 20/30 Post Vitrectomy20/400

Patient: RN 37 year old WM

CC: decreased VA OU

HOPI: 2 week Hx decreased

PMHx: 2001 HIV+

CD4 100

Meds: Combivir

ROS: RA

PE: Psoriasis

Presumed Dx? CMV retinitis

Ocular Exam - RN

VA OD: CF

VA OS: CF

SLE OD: 1+ KP and 1+ vit cells

SLE OS: 1+ KP and 1+ vit cell

FE OD: Disc edema

FE OS: Disc edema and retinitis

Clinical Course - RN

What the………………….?

Famvir 500mg TID

Bactrim DS BID

Labs HIV - Positive

ESR - 60

CRP - 2.7

Toxoplasmosis – Neg

CMV Retinitis?

Famvir 500mg TID

Bactrim DS BID

Labs HIV - Positive

ESR - 60

CRP - 2.7

Toxoplasmosis – Neg

RPR - Positive

FTA Abs – Positive

Syphilitic retinitis

RX IV – Penicillin

Weekly BenzathinePenicillin G IM for 3 weeks

Final VA 20/40 OD

20/50 OS

What the…….?

What the…………………?

AIDS and the Eye

Exudative Retinal Detachments s/p ATB for Syphilis

Patient: LB 62 year old WF

CC: Gray vision OS

HOPI: 3/6/12 - Woke up with

pain and LOV OS

3/16/12 Back to normal!

PMHx: WNL

Meds: Symbacort

ROS: HA, ringing and leg swelling

PE: Rash

Presumed Dx? Retinal vasculitis

Ocular Exam - LB

VA OD: 20/20

VA OS: 20/70

SLE OD: WNL

SLE OS: WNL

FE OD: WNL

FE OS:

Ocular Exam - LB

VA OD: 20/20

VA OS: 20/70

SLE OD: WNL

SLE OS: WNL

FE OD: WNL

FE OS:

Labs: Normal CBC, ESR, CRP

Clinical Course - LB

CRAO with plaque break-up

Retinal Vasculitis

Intra-carotid BCNU

Ocular Exam - MH

VA OD: 20/20

VA OS: 20/70

SLE OD: WNL

SLE OS: Multifocal keratitis

Ocular Exam - MH

VA OD: 20/20

VA OS: 20/70

SLE OD: WNL

FE OD: WNL

FE OS: Vitreous base snowballs

Labs: WNL

Ocular Exam - MH

VA OD: 20/20

VA OS: 20/70

SLE OD: WNL

FE OD: WNL

Labs: WNL

Ophthalmia Nodosa

Ocular Exam - MH

VA OD: 20/20

VA OS: 20/70

SLE OD: WNL

FE OD: WNL

Labs: WNL

Rose Haired Tarantula!

The nevus that got away !

What the…………………!

Patient: DC 11 year old WM

CC: Decreased VA OU

HOPI: 12/8/14 A 5 month Hx of

decreased VA OU and metmorphopsia following a “roller coaster ride”

PMHx: Cystic Hygroma

(Hemangiomatosis)

Permanent trach (2003)

Tracheitis & Pneumonia

Meds: Pred 10 mg

ROS: Unremarkable

PE: Neck tumor/trach

Presumed Dx? Severe Uveitis

Ocular Exam - DC

VA OD: 20/200

VA OS: 20/400

SLE OD: 3+ Cells in A/C and Vit, PSC

SLE OS: 3+ Cells in A/C and Vit, PSC

FE OD: No View

FE OS: No View

Labs: ?

Ocular Exam - DC

VA OD: 20/200

VA OS: 20/400

FE OD: No View

FE OS: No View

Labs: ?

Dx: Panuveitis OU

Rx: Pred 60 mg

Ocular Exam - DC

VA OD: 20/200

VA OS: 20/400

FE OD: No View

FE OS: No View

Labs: Negative!

Dx: Panuveitis OU

Rx: Pred 60 mg

Ocular Exam - DC

12/18/14 OD 20/60

OS 20/70

No cells and poor view of retina

Famvir per pedatrician

12/18/14 That night…Endogenous

Endophthalmitis!

Admitted and put on IV Vanc, Gent, Cefaz, Tamiflu and Acyclovir

Ocular Exam - DC

1/19/15 VA OD 20/80

VA OS 20/100

No view of retina

1/28/15 Diagnostic and

Therpeutic Vitrectomy OU

Results ?

Ocular Exam - DC

1/19/15 VA OD 20/80

VA OS 20/100

No view of retina

1/28/15 Diagnostic and

Therpeutic Vitrectomy OU

Results Stains – Neg

Cultures – Neg

PCR - Neg

2/5/15

Ocular Exam - DC

2/5/15 VA OD 20/40

VA OS 20/100

Photos

Next…. Consult – Augsberger &

Sheilds

Lung Bx and cultures –Positive

Discussed Retina Bx

Started Cipro 500 BID

Progresssive SRF

3/12/15

6/4/15 VA OD 20/60 VA OS 20/200

Patient: WB 73 year old WF

CC: Decreased VA OD

HOPI: 6/30/15 1 month Hx

floaters and decreased VA

PMHx: HBP, MI, Anemia, Shingles

Meds: Amlopidine, MTX, Prednisone 10 mg

ROS: Vitiligo, PulmHistoplasmosis

PE: WNL

Presumed Dx? Acute Retinal

Necrosis (ARN)

Ocular Exam - WB

VA OD: 20/30

VA OS: 20/25

IOP: 40/17

SLE OD: PC IOL, 3+ Vit Cells

SLE OS:

FE OD: Retinitis and Retinal Vasculitis

FE OS: WNL

Labs: ?

Ocular Exam - WB

VA OD: 20/30

VA OS: 20/25

IOP: 40/17

SLE OS:

FE OS: WNL

Labs: FA

Dx: ARN

Ocular Exam - WB

VA OD: 20/30

VA OS: 20/25

IOP: 40/17

SLE OS:

FE OS: WNL

Labs: FA

Dx: ARN

Rx: Famvir 500 mg TID, Pred 60 mg

Ocular Exam - WB

7/14/15 VA better but worse

retinitis on Rx

Labs: HSV +, Toxo +, RPR +

7/15/15 Diagnostic vitrectomy

Cytology

PCR for HSV, VZV, Toxo, CMV, etc.

Start Bactrim (rash)

7/23/15 – POD 7 On Famvir, Doxy

Prednisone 20 mg

Worse Retinitis!

Ocular Exam - WB

6/15/15 7/14/15

Ocular Exam - WB

7/23/15 Vitrectomy Results?

Ocular Exam - WB

The lab received and logged the specimen in for cytology but forget to process the PCR!

Ocular Exam - WB

We called to do PCR but the specimen had been destroyed!

Ocular Exam - WB

We called to do PCR but the specimen had been destroyed!

Cytology – No malignancy, lymphocytes and macrophages

Ocular Exam - WB

Cytology no malignancy, lymphocytes and macrophages

Ocular Exam - WB

7/30/15 VA 20/30

Worse Retinitis!

On Famvir 500 mg TID

Doxycycline 100mg BID

Prednisone 20 mg

Ocular Exam - WB

7/14/15 7/23/15

Ocular Exam - WB

7/30/15 8/20/15

Ocular Exam - WB

7/30/15 What now?

8/20/15 VA 20/30

Better

Still on Famvir 500 mg TID

Doxycycline 100mg BID

Prednisone 20 mg

Osurdex

Patient: JW 70 year old WM

CC: Floaters and blurred VA OS

HOPI: Decreased VA 6 months following brain surgery

PMHx: 6/08 Lung infection

6/08 Brain surgery

Meds: IV Bactrim and PO Doxycyline

ROS: Hoarse

PE: N/A

Presumed Dx? Fuch’s

HeterochromicIridocyclitis

Toxoplasmosis-like Scar

Ocular Exam - JW

VA OD: 20/25

VA OS: 20/50

SLE OD: PC IOL

SLE OS: 2 3 + diffuse stellate KP

2 + Vit Cells

FE OD: WNL

FE OS: Large chorioretinitis

Multifocal chorioretinitis

Labs: N/A

What the……..?

Clinical Course - JW

Diagnostic and therapeutic vitrectomy

Intaocular antibiotics: Amikacin

Ceftazidime

Cultures: Acid fast bacilli

Continue IV Bactrim

Resolution of vitiritis, inactive chorioretinalscar and return of 20/30 VA

Endogenous Nocardiaendophthalmitis

Silk Route

Fig. 3 Effect of adaptive introgression of Neandertal HLA class I alleles on modern human populations.

L Abi-Rached et al. Science 2011;334:89-94

Published by AAAS

Fig. 1 Modern humans acquired HLA-B*73 from archaic humans.

L Abi-Rached et al. Science 2011;334:89-94

Published by AAAS

Sooty Mangabey & Bonobo Chimpanzee

Sooty Mangabey(Low SIV & HIV-2) Bonobo (10K)

(SIV Negative)

Face and Female

Chimpanzee – Pan troglodyte

Western Chimps (38K) (SIV Negative)

Nigerian Chimps (6K) (SIV Negative)

Sooty Mangabey, Bonobo and Chimpanzee

Eastern Chimp (98K) (SIV Positive)

Central Chimp (93K) (SIV Positive)

Bonobos

Western and Nigerian ChimpsNo SIV Central and Eastern

No SIV

Air Travel

Achoo.Following a sneeze, high-speed video and image processing visualized a waterfall of large droplets (left) and a lingering cloud of small droplets (right) that can spread pathogens

farther.

E Pennisi Science 2014;343:1194-1197

Published by AAAS

Fluid fragmentation from hospital toilets – 80-90 psi (surface tension and detergent) – High speed video 1000 frames per second! C. difficile anyone?

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