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Patient Presentation: A 23-year-old obese female was diagnosed with idiopathic intracranial hypertension (IIH) and referred to neurosurgery for ventriculoperitoneal shunt. A baseline ocular examination was performed prior to the procedure.

On examination, vision was 20/200 in the right eye, and 20/40 in the left eye. There was a right relative afferent pupillary defect. Slit lamp examination was normal.

A dilated fundus examination was performed demonstrating the following:

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Uveitis

Case 6

Contributor: Dr. Safwan Tayeb, MD

Patient Presentation: A 63-year-old male referred by his optometrist presented with a 1-week history of blurry vision OD. His past medical history was significant for recent genital warts, but negative for systemic inflammatory conditions; past ocular history was unremarkable. The patient smokes 1/2 pack-a-day of cigarettes and disclosed that he is sexually active with multiple partners, both male and female. He does not use protection.

His visual acuity was counting fingers OD and 20/25 OS, with normal IOP and extraocular movements. Slit lamp examination found clear corneas but 2+ AC cells OD and 1+ AC cells OS with mild conjunctival injection OU. Colour fundus photos below demonstrate OD optic disc swelling and hyperemia with a deep yellowish placoid chorioretinal lesion over the posterior pole involving the macula.

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Question: The OD OCT macula is shown above. Which finding is NOT seen in the above OCT macula?

A. Deep granular changes at the level of the RPE

B. Disruption of outer retinal layers

C. Disorganization of inner retinal layers

D. Thickened choroid

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Question: The OD fundus autofluorescence image is shown above, demonstrating extensive hyper-autofluorescence throughout the posterior pole. Based on the patient’s provided history, anterior chamber inflammation, and outer retinal abnormalities, what investigations would be most pertinent at this time?

A. Syphilis and HIV serology

B. Skin lesion biopsy

C. Complete blood count

D. Anterior chamber tap

Question: What treatment should now be initiated based on the above serology results?

A. Conservative approach with topical steroids and atropine for cellular activity

B. Referral to infectious disease for IV penicillin treatment and lumbar puncture to rule out neurosyphilis

C. 1 g Azithromycin PO once

D. 100 mg Doxycyline PO for 7 days

Looking back at the initial OCT, the granular excretions throughout the RPE in the setting of panuveitis and a posterior placoid chorioretinal lesion are pathognomonic for ocular syphilis (green arrow).

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Learning Objectives:

1. To understand the findings pathognomonic for ocular syphilis.

2. To determine the management for patients suspected of ocular syphilis and posterior placoid chorioretinitis.

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