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64-year-old woman was in the office on May 6, 2010. She has noticed over the last three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. You saw a problem in the eye and suggested that she come here for an evaluation. She does have an unusual medical history. In her twenties she was feverish and sick on and off for about twenty years and she has noticed that she really never had a diagnosis for that. She did have an episode of malaria in 1948 that was treated. She was told at one point she could possibly have had Familio Mediterranean fever. She does intermittently get rashes around her arms. She has arthritis in her knees and ankles. She does not have any breathing problems accept for a cough now and then. She has thyroid disease and Grave’s disease and she does not have any eye pain or pain on eye movement. VISUAL ACUITY: OD 20/40, OS 20/50. IOP: OD 14, OS 15. SLIT EXAMINATION: There is 3+ nuclear sclerosis in both eyes. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.1. There is posterior vitreous separation and 2+ anterior vitreous cells. There is a 1+ epiretinal membrane. There are patchy areas of a deep pigmentation of the choroid, predominately inferior to the optic nerve. There is also irregularity of the retinal veins with irregular caliber. OS: Vertical C/D ratio is 0.1. There is posterior vitreous separation and 2+ epiretinal membrane. There are some depigmented areas of the choroid and the veins are irregular. Photos confirm clinical findings. FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography shows leakage from the retinal veins as well as the retinal capillaries in the late frames. There is intense staining of the optic nerve and there is some irregularity of the retinal veins. IMPRESSION: 1. POSTERIOR UVEITIS – RIGHT EYE WITH PERIPHLEBITIS 2. CYSTOID MACULAR EDEMA – RIGHT EYE 3. MACULAR PUCKERS – BOTH EYES 4. POSSIBLE GRANULOMATOUS CHOROIDITIS 5. CATARACT DISCUSSION: I explained to the patient her symptoms are attributable to her cataracts, but I agree she does look like she has a uveitis syndrome, most consistent with probably sarcoidosis. I am going to obtain blood tests on her as well as a chest x-ray PA and lateral. She has done a lot of traveling. She was born in Morocco and I am going to make sure she is tested for tuberculosis as well. I asked her to return here for a check in one month. I think cataract surgery would ultimately help her vision, but because of the diffuse uveitis and vasculitis she probably will need steroid coverage, both prior to and after the cataract surgery. At this moment I am not going to treat her with any steroids. Thank you for allowing me to participate in her care. HLA - A29 was positive and other lab tests were all negative. Clinical picture most likely Birdshot Chorioretinitis

birdshot_hebe25.png
Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 224 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 139 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 153 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 123 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 100 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 110 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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birdshot_hebe06.png
Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 98 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 88 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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birdshot_hebe08.png
Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 73 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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birdshot_hebe09.png
Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 84 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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birdshot_hebe10.png
Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 81 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 106 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 136 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 74 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 84 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 88 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 66 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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birdshot_hebe17.png
Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 89 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 64 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 63 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 81 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 82 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 153 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
00000
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 135 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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Birdshot Chorioretinitis - Retinal Vasculitis - HLA A29 Positive 201 views64-year-old woman three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. PMHx: malaria in 1948 that was treated. She was told at one point she could possibly have had Familial Mediterranean fever.

She does intermittently get rashes around her arms. She has arthritis in her knees and ankles.
VISUAL ACUITY: OD 20/40, OS 20/50 - HLA - A29 Positive
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64-year-old woman was in the office on May 6, 2010. She has noticed over the last three or four year’s fluctuations in her vision. She mostly notices them in bright light her vision glares out and she has difficulty seeing. You saw a problem in the eye and suggested that she come here for an evaluation. She does have an unusual medical history. In her twenties she was feverish and sick on and off for about twenty years and she has noticed that she really never had a diagnosis for that. She did have an episode of malaria in 1948 that was treated. She was told at one point she could possibly have had Familio Mediterranean fever. She does intermittently get rashes around her arms. She has arthritis in her knees and ankles. She does not have any breathing problems accept for a cough now and then. She has thyroid disease and Grave’s disease and she does not have any eye pain or pain on eye movement. VISUAL ACUITY: OD 20/40, OS 20/50. IOP: OD 14, OS 15. SLIT EXAMINATION: There is 3+ nuclear sclerosis in both eyes. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.1. There is posterior vitreous separation and 2+ anterior vitreous cells. There is a 1+ epiretinal membrane. There are patchy areas of a deep pigmentation of the choroid, predominately inferior to the optic nerve. There is also irregularity of the retinal veins with irregular caliber. OS: Vertical C/D ratio is 0.1. There is posterior vitreous separation and 2+ epiretinal membrane. There are some depigmented areas of the choroid and the veins are irregular. Photos confirm clinical findings. FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography shows leakage from the retinal veins as well as the retinal capillaries in the late frames. There is intense staining of the optic nerve and there is some irregularity of the retinal veins. IMPRESSION: 1. POSTERIOR UVEITIS – RIGHT EYE WITH PERIPHLEBITIS 2. CYSTOID MACULAR EDEMA – RIGHT EYE 3. MACULAR PUCKERS – BOTH EYES 4. POSSIBLE GRANULOMATOUS CHOROIDITIS 5. CATARACT DISCUSSION: I explained to the patient her symptoms are attributable to her cataracts, but I agree she does look like she has a uveitis syndrome, most consistent with probably sarcoidosis. I am going to obtain blood tests on her as well as a chest x-ray PA and lateral. She has done a lot of traveling. She was born in Morocco and I am going to make sure she is tested for tuberculosis as well. I asked her to return here for a check in one month. I think cataract surgery would ultimately help her vision, but because of the diffuse uveitis and vasculitis she probably will need steroid coverage, both prior to and after the cataract surgery. At this moment I am not going to treat her with any steroids. Thank you for allowing me to participate in her care. HLA - A29 was positive and other lab tests were all negative. Clinical picture most likely Birdshot Chorioretinitis