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Chief complaint
Mr. BH (a 37-year-old male) reported curtain or cottonlike vision, increasing floaters for 1 month. Mild redness.
History
Past medical history: HIV+ for 7 years. T-cell and viral loads normal. Hepatitis C for 1 year. Systemic CMV for 2 years. Medications: Sustiva, Cambivir, acyclovir, Xanax, interferon alpha, ribavirin.
Past ocular history: Exam one year ago with no retinopathy.
Exam
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OD |
OS |
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Best corrected visual acuity: |
20/20- |
20/20- |
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External: |
1+ diffuse perilimbal injection |
1+ diffuse perilimbal injection |
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Slit lamp: |
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IOPs (applanation tonometry): |
49mmHg |
46mmHg |
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Gonioscopy: |
open angles, no peripheral anterior synechiae (PAS) |
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Dilated fundus exam: |
1+ vitreal cells, inferior vitreous snowball opacities, 1 cotton wool spot (OS), optic nerve heads flat, and C/Ds 0.3. No CMVR; no snowbanking exudates. |
Assessment
- Bilateral granulomatous uveitis (etiology?); further review of medical systems negative
- Bilateral secondary glaucoma; in-office treatment
- HIV+
- Hepatitis C with interferon treatment
Plan/Treatment
Get pressures down, bring inflammation under control.
- 1% Pred Forte ophthalmic susp q2h OU
- 5% homatropine qhs OU
- In-office treatment: Beta blocker and Alphagan P (IOPs: 32mmHg OD, 30mmHg OS)
- 0.5% Betimol qam and continue Alphagan P bid
- Follow-up: 1 day (IOPs: 22mmHg OD, 21mmHg OS)
- Refer to infectious disease specialist (doctor patient had been seeing) for further lab tests
- 1-month follow-up: Resolved uveitis and cotton wool spot. No signs of retinitis. Lab studies normal.
- 2-month follow-up: Resolved uveitis but new complaint of irritated OS with poor eyelid closure, drooping of left side of face (diagnosis: Bell's palsy; treatment with Thera tears gel, Valtrex, and prednisone).
- 3-month follow-up: Resolved Bell's palsy.
- 6-month follow-up: Reactivation of granulomatous uveitis with new skin lesion on leg. Refer for more lab tests--especially to rule out sarcoidosis.
| Why chronic granulomatous uveitis and cotton wool spot?
Interferon is a protein produced naturally by certain white blood cells as a part of the immune response to fight infections or cancer. Interferon alpha is a drug made to serve the same role. It is commonly used to fight Hepatitis C (sometimes in combination with ribavirin) and cancer. Interferon alpha can only be given subcutaneously. Common side effects include flu-like symptoms which tend to diminish as course of treatment continues. Interferon treatment has been associated with granulomatous uveitis and cotton wool spots. |
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