Case 6

Chief complaint
A 62-year-old male presented with mild pain, red eye, photophobia, blurring of vision, and tearing OS.

History
Key ocular history: Previous attacks of iritis.
Medical history: No current medical diagnoses.

Exam

	OD	OS
Best corrected visual acuity:	20/25	20/30
Slit lamp:	classic mutton fat keratic precipitates (KPs) in both eyes--similar to those seen in Case 5 patient; look for systemic cause when see KPs [view video 1]     [view video 2]

Assessment: Bilateral chronic granulomatous uveitis with mutton fat KPs

Plan/Treatment

• Cycloplegic (5% homatropine qid OU)
• Topical steroids (Pred Forte q2h OU)
• Refer to internist for medical workup and uveitis laboratory tests

  Lab tests suggested for bilateral, granulomatous, or recurrent anterior uveitis
  Complete blood count (CBC) Erythrocyte sedimentation rate (ESR) Antinuclear antibody test (ANA) Rapid plasma reagin (RPR)/venereal disease research laboratory (VDRL) Fluorescent treponemal antibody absorption (FTS-ABS) or microhemagglutination assay for antibodies Treponema pallidum (MHA-TP)	Purified protein derivative (PPD) and anergy panel Chest x-ray for sarcoidosis and tuberculosis Lyme titer in endemic areas Consider HLA-B27 Angiotensin converting enzyme (ACE)

• Follow-up: Sarcoidosis, multiple recurrences of uveitis, cataract, steroid responder, cystoid macular edema (CME)

Sarcoidosis is a multi-system disease which causes an inflammation of the body tissues. The inflammation produces granulomas (nodules) in the affected tissues. It most frequently presents as thoracic lymphadenopathy, lung parenchymal abnormality, and skin/eye lesions. Although sarcoidosis occurs in patients of all ages, most are between 20 and 40 years. The cause is unknown.
Focal Points Granulomatous iritis--mutton fat KPs Vitritis--snowball opacities Vasculitis--sheathing of veins Candle-wax drippings	Key Systemic Signs Bilateral hilar adenopathy Erythema nodosum Arthritis Lymphadenopathy Hepatosplenomegaly Salivary gland enlargement Facial nerve palsy	Lab Tests Positive for Sarcoidosis Chest x-ray ACE Biopsy of any conjunctival granulomas Gallium scans of head and neck Serum lysozyme Pulmonary function tests Skin, lymph node, or lung biopsy