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“Doc, my eye is blurry!” Panuveitis: Diagnosis, Decisions and Differentials
Anna Lange, OD
SUNY/Fromer Eye Centers (Private Practice Co-Management)
Each case report is required to begin with an abstract, limited to 35 words (present tense),
describing the case.
The case describes an initial presentation of panuveitis in an otherwise healthy male. It
highlights appropriate lab work up, differentials treatment and management. Furthermore, OCT
imaging is utilized to monitor for improvement from baseline.
I. Case History
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Patient demographics
42 year old Hispanic male
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Chief complaint
Worsening blurred vision and mild photophobia OS x 3 weeks
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Ocular, medical history
Trauma OD as a child
Oculoplastics procedure 07/21/15 for epiphora
Medical history non-contributory
No recent travel
No trauma OS
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Medications
None
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Other salient information
Complained of new onset of floaters on 07/21/15 at oculoplastics consultation, but patient
declined a dilated fundus examination at that time
 VA OD: 20/20
VA OS: 20/20
 (-) anterior chamber reaction
 (-) PVD
Last exam with dilated fundus examination 05/01/2015
 VA: 20/20 OU
 IOP: 18/21 mm Hg
 DFE: WNL OU
II. Pertinent findings
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Clinical
VISIT #1: 08/06/2015 (3 weeks after initial complaint)
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VA OD: 20/20
VA OS: 20/50 PH: 20/40
EOMs: Full, intact OU
Pupils: PERRL(-) APD
IOP: 14 mm Hg OU
SLE OS:
o Cornea: diffuse pigmented endothelial KPs (-) staining
o AC: grade1+ cells (-)flare
DFE OS:
o Vitreous: grade 3 vitritis, inferior vitreal traction (+) snow banking
o ONH: 0.40 (-)edema
o Vessels: WNL
o Macula: (+) edema
o Periphery: inferior white multiple lesions at level of RPE, hazy view
secondary to vitritis (-) chorioretinal scarring (-) RD/RT
Mac OCT to document macular edema
VISIT #2 (1 day follow up):
 VA OD: 20/20
 VA OS: 20/50 PH: NI
 EOMs: Full, intact OU
 Pupils: PERRL(+) pharmacological pupil
 IOP: 17/19 mm Hg OU
 SLE OS:
o Cornea: diffuse pigmented and non-pigmented endothelial KPs (-) staining
o AC: grade 1+ cells (-)flare
 DFE OS:
o Vitreous: grade 2+ vitritis, inferior vitreal traction (+) snow banking
o ONH: 0.40 (-)edema
o Vessels: WNL
o Macula: (+) edema
o Periphery: inferior vitreous snowball, hazy view secondary to vitritis (-)
chorioretinal scarring (-) RD/RT
VISIT #3 (5 day follow up):
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VA OD: 20/20VA OS: 20/100 PH: 20/40
EOMs: Full, intact OU
Pupils: PERRL(+) pharmacological pupil
IOP: 13 mm Hg OU
SLE OS:
o Cornea: diffuse pigmented endothelial KPs (-) staining – KPs
reduced/improved
o AC: grade 1 cells (-)flare
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DFE OS:
o Vitreous: grade 1-2 vitritis, inferior vitreal traction (+) snow banking
o ONH: 0.40 (-)edema
o Vessels: WNL
o Macula: (+) edema
o Periphery: inferior vitreous snowball, hazy view secondary to vitritis (-)
chorioretinal scarring (-) RD/RT
VISIT #4 (1 week follow up):
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VA OD: 20/25
VA OS: 20/80 PH: 20/40
EOMs: Full, intact OU
Pupils: PERRL(+) pharmacological pupil
IOP: 14 mm Hg OU
SLE OS:
o Cornea: trace pigmented and non-pigmented endothelial KPs (-) staining –
KPs essentially resolved
o AC: grade 1 cells (-)flare
DFE OS:
o Vitreous: grade 1+ inferior vitritis (improving) (+) snowballs
o ONH: 0.40 (-)edema
o Vessels: WNL (-)sheathing (-)vasculitis
o Macula: (+) edema with RPE mottling
o Periphery: inferior vitreous snowball, hazy view (with improvement)
secondary to vitritis (-) chorioretinal scarring (-) RD/RT
VISIT #5 (2 week follow up):
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VA OD: 20/15
VA OS: 20/50+1 PHNI
EOMs: Full, intact OU
Pupils: PERRL(+) pharmacological pupil
IOP: 16 mm Hg OU
SLE OS:
o Cornea: resolved KPs (-) staining
o AC: grade 1 cells (-)flare
DFE OS:
o Vitreous: trace/1 vitreous cells, inferior vitritis resolving (+) snowballs
o ONH: 0.40 (-)edema
o Vessels: WNL (-)sheathing (-)vasculitis
o Macula: improving edema with mild RPE mottling
o Periphery: resolving inferior vitreous snowball, improving view (-)
chorioretinal scarring (-) RD/RT
Physical
None
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Laboratory studies
(-) Toxo IgM
(-) ACE
(-) HSV/HZV IgM
(-) RPR
(-) FTA-ABS
(-) Lyme
(-) ESR
(-) PPD
(-) HIV
(-) RF
(-) ANA
HLA B27 – pending
HLA B51 – not performed
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Radiology studies
Chest X-ray WNL
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Others
Macular OCT
VISIT #1 (initial presentation): image; sub-retinal fluid OS
VISIT #5 (2 weeks post baseline): image; improving macular edema OS
III. Differential diagnosis
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Primary/leading
o Idiopathic
o Toxoplasmosis gondii
o Sarcoidosis
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Others
o
o
o
o
o
o
Toxocariasis
CMV/HZV/HSV
Sympathetic Ophthalmia
Vogt-Koyanagi-Harada Syndrome
Behcet Disease
ARN
IV. Diagnosis and discussion
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Elaborate on the condition
o Panuveitis – new onset, first time occurrence
o Posterior vitritis with minimal anterior spillover
o
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Patient was prescribed topical steroids and instructed to RTC 1 day with vitreoretinal specialist
o Over the course of the next 2 weeks, patient was closely monitored in the retina
clinic and treatment was altered as deemed necessary
Expound on unique features
o Macular OCT aided in monitoring macular edema
o All laboratory work up was negative
V. Treatment, management
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Treatment and response to treatment
 Prescribed Pred Forte Q2H OS and 1 gtt Cyclopentolate 1% instilled in office at time
of initial visit (visit #1)
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Due to stability of vision and findings on 1 day follow up, patient was maintained on
Pred Forte Q2H OS
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As vision continued to decline on 3rd visit despite topical steroid and improvement of
anterior uveitis, oral Prednisone 80mg TAB QAM daily was initiated
Pred Forte and Cyclopentolate were continued as previously prescribed
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With initiation of oral Prednisone, vitritis began to slowly improve along with mild
resolution of anterior uveitis. Therefore, topical Pred Forte was reduced to Q3H OS.
Cyclopentolate and oral Prednisone were continued as previously prescribed
On 1 week follow up after initiating oral Prednisone, there was great improvement
with the anterior and posterior uveitis. Oral Prednisone was tapered to 60mg TAB
QAM daily x 1 week and 40mg TAB QAM daily x 1 week until the 2 week follow up
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Pred Forte was reduced to Q4H OS and Cyclopentolate was continued BID OS
The patient is continually monitored under the care of a retinal specialist at this time.
Refer to research where appropriate.
 Initially, blood work is essential to rule out tuberculosis, Lyme and/or syphilis. Once
etiology is established, treatment may be initiated. In this particular case, all results
were negative – leading to an idiopathic presentation. Nonetheless, the visual acuity
was worsening along with no improvement in the vitritis with the topical steroids.
Therefore, oral steroids were prescribed.
 As research indicates, primary visual acuity outcome provides a better evaluation of
effectiveness of treatment. Once the visual acuity and panuveitis began to improve, a
taper schedule was initiated.
 A randomized comparison of systemic vs. intra-vitreal implantable corticosteroid was
assessed in the Multicenter Uveitis Steroid Treatment Trial (MUST.) The two
treatment options were comparable in the visual acuity outcome. The patient received
the oral steroid in this particular case with marked, gradual improvement.
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Since macular edema has been documented as a presentation of panuveitis, a baseline
macular OCT was obtained. A follow up macular OCT was taken to document early
stages of resolution.
Bibliography, literature review encouraged
o Arevalo, J. et al. Update on Sympathetic Ophthalmia. Middle East African
Journal of Ophthalmology. 2012, 19(1): 13-21.
o Bansal, R., Gupta, V. and Gupta, A. Current Approach in the Diagnosis and
Management of Panuveitis. Indian Journal of Ophthalmology. 2010: Jan-Feb; 58
(1): 45-54.
o Ganatra, J. et al. Viral Causes of the Acute Retinal Necrosis Syndrome. American
Journal of Ophthalmology 2000; 129: 166-172.
o Gerstenblith, A., Rabinowitz, M. The Wills Eye Manual: Office and Emergency
Room Diagnosis and Treatment of Eye Disease. Wolters Kluwer: 2012: Sixth
edition. Gore, D., Gore, A., Visser, L. Progressive Outer Retinal Necrosis.
Archives of Ophthalmology. 2012; 130(6): 700-706.
o Lau C. et al. Acute Retinal Necrosis: Features, Management, and Outcomes.
Ophthalmology 2007; 114: 756-762.
o The Multicenter Uveitis Steroid Treatment (MUST) Trial Research Group,
Kempen, J. et al. Randomized Comparison of Systemic Anti-inflammatory
Therapy versus Fluocinolone Acetonide Implant for Intermediate, Posterior and
Panuveitis: The Multicenter Uveitis Steroid Treatment Trial. Ophthalmology,
2011. October; 118(10): 1916-1926.
VI. Conclusion
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Clinical pearls, take away points if indicated
 Know how to work up panuveitis appropriately to obtain the best
differentials/treatment for the patient
 Know appropriate treatment and follow up schedule
 Know how to use imaging in order to document baseline clinical findings as well
as improvement/progression