Joshua Uhr, MD
Bascom Palmer Eye Institute
This session, “There Are All Kinds of Love in the World but Never the Same Love Twice,” included presentations of interesting and complex uveitis cases. Ashleigh Levison, MD; Ashvini K Reddy, MD; and Eduardo Uchiyama, MD moderated the discussions.
First, Parisa Emami, MD presented a case of a 75-year-old female with vitreoretinal lymphoma. Prior to diagnosis, the patient had chronic uveitis for years with a partial response to steroids. She had a negative uveitis workup and negative previous vitreous biopsy. During her course, she developed new multifocal yellow subretinal lesions. Repeat diagnostic vitrectomy and choroidal biopsy was performed, and cytology revealed large B-cell lymphoma. Brain MRI demonstrated multiple metastatic lesions. The patient unfortunately passed away from her CNS disease shortly after. Dr. Emami recommended the following take home points: 1) always think about masquerades and 2) have a low threshold for diagnostic vitrectomy when the clinical situation does not respond as expected or for uveitis in older patients. Also consider biopsy if there is tissue available.
The panel noted that the vitreous biopsy can be falsely negative in cases of vitreoretinal lymphoma. In order to increase the diagnostic yield during vitrectomy, Dr. Emami recommended stopping steroids before biopsy, taking undiluted vitreous samples for cytology using a low cut rate, and discussing the case with the pathologist prior to surgery to coordinate how to best provide the specimen. Dr. Thomas Albini commented that in cases in which the biopsy and neuroimaging are negative but the suspicion remains high for lymphoma, performing serial MRIs may detect brain lesions that develop over time.
Next, Kareem Moussa, MD presented a case of chronic post-operative endophthalmitis after uncomplicated cataract surgery. The patient had a negative anterior chamber tap performed elsewhere and a negative systemic uveitis workup before he was referred to Dr. Moussa. The patient was treated with steroids but had recurrent inflammation each time the steroids were tapered. Dr. Moussa repeated the anterior chamber tap, which was positive for Cutibacterium acnes (C. acnes). The patient underwent vitrectomy with intraocular lens and capsular bag explanation (see photo). Dr. Moussa concluded that in cases of suspected infectious uveitis, consider repeating the anterior chamber tap yourself. Moreover, C. acnes is a condition that usually requires surgical intervention.
Intraoperative photo demonstrates infectious white material on the capsular bag after removal from the eye
The next presentation, by Arjun B. Sood, MD, was a case of acute retinal necrosis. The patient was initially managed elsewhere with topical steroids for iritis before being referred to Dr. Sood for worsening vision. She was found to have retinal necrosis and was managed with oral valacyclovir and serial intravitreal foscarnet injections. Two weeks after treatment initiation, she returned with a total retinal detachment. After undergoing scleral buckle placement and vitrectomy with ILM peel under perfluorocarbon liquid, the patient did well. Dr. Uchiyama asked about early laser for retinal detachment prophylaxis, which Dr. Sood does not typically perform.
Next, Akshay S. Thomas, MD shared a case of 5-year-old girl with toxocara chorioretinitis. She presented with panuveitis and a macular lesion (see photo). Labs were drawn and she was treated empirically with Bactrim. Two days later, she returned with opacification and contraction of the vitreous over the lesion. She underwent vitrectomy and the plaque was peeled. PCR from a vitreous sample was positive for toxocara. Dr. Thomas offered the following tips for these challenging surgical cases: examine the periphery before placing trochars to ensure you do not place the trochar through a granuloma or other lesion, discuss the possible lab tests with the lab before the case, know when to stop (i.e. peeling ILM may prevent epiretinal membrane, but is too risky in the setting of necrotic and edematous retina), and pay attention to drug concentrations under air.
Photo: Macular lesion at presentation
Photo: The macular lesion two days later, with opacification and contraction of the vitreous over the lesion
Finally, Arthi G. Venkat presented the last case of the session, a patient with chronic post-operative endophthalmitis with a surprising etiology: Aquamicrobium Terrae. This organism has only been identified in industrial soil in China, but the patient had no travel history to China, so the source of the microbe was a mystery. She was treated with serial intravitreal antibiotic injections based on culture sensitivities, but continued to have recurrent inflammation, so the intraocular lens was explanted. The patient continued to have recurrent inflammation, and UBM identified a thick membrane under the iris. Endoscopic vitrectomy was subsequently performed to remove this. Dr. Venkat highlighted that endoscopic vitrectomy is a useful technique for direct visualization of retained posterior capsular material posterior to the iris. The eye has since remained quiet.
The panel discussion highlighted that this case – and several of the other cases presented in the session – demonstrate the importance of determining if intraocular inflammation is infectious or malignant. Steroids can mask both of these entities.