33 year old army man presented to our uveitis clinic with loss of vision in his RE of 2 weeks duration.
1 month earlier he had presented to Manchester Royal eye hospital with, what sounded like, an Anterior uveitis. He was treated with topical steroids.
He then went back to his
family in West Wales where he attended an eye emergency clinic, here it
was thought he had vitreous cells. Oral Prednisolone 60mgs was commenced as the diagnosis of Sarcoidosis was presumed.
He was then seen the following week, his VA had dropped and signs of his uveitis had become worse. An orbital floor Triamcinolone was given.
A week
later he was seen again and the fundal appearance are shown in the photos. (Hence the
referral to our uveitis clinic).
He was admitted and given IV Aciclovir 1 gram tds. Gradual improvement on this treatment was seen.
He later relocated to Manchester and VA on discharge was 6/12.
Questions:
What in your opinion is the cause of his Uveitis?
Where was the first mistake?
What was the second mistake?
What in your opinion we should have done?
Is barrier laser indicated
Answers:
Acute Retinal Necrosis (ARN)
The first mistake: Failure to look at the fundus, to know this not an Anterior uveitis that you could treat with topical steroid
Second mistake: Failure to identify ARN or retinitis which is an Ophthalmic emergency.
A tap should have been done
Barrier laser in this case was not possible because the retinitis was so aggressive that is had progressed to the macula region and therefore could not be walled in.