Kimia Letafat of SUNY 2013 is the winner of the January 2013 Clinical Case Review. This is the premier resource for optometry students to post their most interesting optometric clinical cases online for all to see. A winner will be chosen monthly and will receive a clinical gift bundle, an official certificate signed by the founder of OptometryStudents.com and their clinical case will be promoted for the optometry community to see and enjoy.
Age/Sex/Race:
18 year old Hispanic male
Chief Complaint:
Slight distance and near vision blur beginning 4 days ago lasting all day. Patient has never worn spectacles. Reports an associated onset of floaters 4 days ago.
Medical History:
Last medical exam: 4 months ago without blood work. Patient reports medical health “all normal”
(-)HTN, DM
NKA, KNDA
Ocular History:
This is patient’s first eye exam
(-) ocular pain, burning, itching, redness, tearing, headaches, double vision, flashes of light, recent trauma, spectacle correction
Family History:
Unremarkable
Initial diagnosis and plan of action:
Considering this is the patient’s first eye exam, my initial diagnosis was an uncorrected refracted error causing distance/near vision blur that the patient recently became aware of. Other causes of acute onset painless blurry vision can be ruled out due to the patient’s age and healthy medical status (eg: retinal vascular occlusions secondary to systemic conditions such as Diabetes or Hypertension). I was eager to get onto the refractive part of the exam to clear up the blurry vision my patient was experiencing.
External Findings:
Distance visual acuity (uncorrected)
OD: 20/25 PH: NI
OS: 20/20
Extraocular muscles: FULL, 4 OU
Confrontational Visual Fields: Full two finger count OD/OS
Pupils: PERRL(-)APD
Manifest Refraction:
OD: plano VA: 20/25
OS: plano VA: 20/20
At this point in the exam, I knew that my initial diagnosis was incorrect. There was no refractive error causing the decrease in vision, which appears to be in the right eye. After eliminating refractive error as the source of blur, my next step was to assess the ocular health of the anterior segment:
Biomicroscopy:
Lids/lashes: clear OD/OS
Conjunctiva: clear OD/OS
Cornea: small inferior keratic precipitates OD, clear OS
Anterior Chamber: grade 1 cells/flare OD, clear OS
Angles: open OD/OS
IOPs:
OD: 48mmHg
OS: 18mmHg
At this point, I discovered an Anterior Chamber reaction accompanied with an increased intraocular pressure in the right eye. This explains the blur experienced by the patient. My diagnosis at this point was Posner Schlossman Syndrome (also known as Glaucomatocyclitic Crisis). This syndrome typically affects young to middle-aged adults who develop unilateral recurrent episodes of high intraocular pressure with a mild anterior chamber reaction. It can cause blurry vision, haloes around lights, and minimal discomfort in the eyes. I then proceeded to check in with my supervisor explaining the findings up until this point. She agreed that my diagnosis might be valid, but that a dilated fundus exam would need to be performed to examine the optic nerve and retina.
Dilated Fundus Exam:
Lens: clear OD/OS
C/D: OD unable to assess due to obscuring vitritis, clear OS
Posterior pole: OD white hazy retinal lesion 1 disc diameter superior/nasal to disc with overlying vitritis, blurred disc margins, and retinochoroiditis. OS clear
Macula: clear OD/OS
Periphery: Flat and intact, no holes, no tears 360 OD/OS
I took a good look at the right eye with my 90D lens, and immediately called my supervisor into the room. I explained exactly what my findings were and I was then asked if my diagnosis had changed. At this point, I knew that Posner Schlossman Syndrome was not the correct diagnosis because there was something clearly going on in the posterior segment of the eye. I was still unsure of the diagnosis as I had never seen a fundus with this type of appearance. My supervisor then asked me again to explain my fundus findings paying close attention to the vitritis. It then dawned on me, I had just discovered a case of active Toxoplasmosis! Once I explained the vitritis I remembered the saying “headlights in the fog” from my retina course, and that is exactly what I was seeing!
The following image is not of my patient, but has a very similar fundus appearance:
Image Credit: Review of Ophthalmology: “Wills Eye Resident Case Series-Diagnosis and Discussion”
What was your assessment and plan? (include diagnosis, treatment and follow up):
Toxoplasmosis can cause unilateral mild ocular pain along with blurry vision secondary to macular involvement or severe vitreal inflammation. The vitreal inflammation in this case is was what caused the onset of floaters and it may also cause photophobia. One can also experience a red eye due to the anterior uveitis from overspill of the posterior segment. In the fundus you may see white-yellow chorioretinal lesions with an overlying vitritis and haze. Often times active Toxoplasmosis may recur adjacent to an old pigmented retinochoiroidal scar.
The diagmosis of Toxoplasmosis is by clinical observation of a focal necrotizing retinochoroiditis.
After determining a diagnosis it was now time to bring down the pressure in the right eye in office. We used one drop of Combigan, and one drop of Azopt, which brought down the pressure from 48mmHg to 42 mmHg. Fifteen minutes later we instilled another drop of Combigan and Azopt bringing the pressure down to 35mmHg. We also instilled 2 drops of Lotemax for the concurrent anterior chamber reaction.
At this point, we referred the patient to a retina specialist same day and instructed the patient to continue the following treatment until otherwise told:
- Combigan BID OD, Azopt BID OD
- PredForte q2h OD
- Cyclopentolate BID OD
This case is a good example that it is important to think dynamically in a clinical setting and to not get fixated on one particular diagnosis. Remember to carefully assess all objective and subjective findings relating to the refraction, anterior segment, and posterior segment before making a definitive diagnosis!
