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Visit 1: 12-06-12 74-year-old man was seen in the office on December 3, 2012. He was doing fine until just a few months ago when he started noticing vision loss, first in the right eye than the left. Then the left eye had cataract surgery done back in July. He has noticed recently he is getting tired easily. He gets weak. He can’t walk for a long distance. He has lost five pounds within the last month and he also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. He does have a positive FTA-ABS, suggesting he might have syphilis, however, he had a spinal tap, which was negative. MRI initially revealed a mass lesion of the occipital lobe however repeat scanning with contrast showed the suspect area simply to be artifact. Further testing was ordered including lumbar puncture and blood testing which revealed a negative RPR, VDRL, Toxo titre, Cryptococcus and lyme titre. A vitreous sample (PPV) had negative PCR for lyme, toxo, HSV, HS and DNA for TP all of which were negative. VISUAL ACUITY: OD 1/200, OS 20/63. IOP: OD 14, OS 12. The right eye has 1+ cell and flare of the anterior chamber and a ReSTOR intraocular lens in good position. He also has corneal incisions. The left eye has a trace cell and flare of the anterior chamber and a ReSTOR intraocular lens in good position. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.2. There is a white intraretinal mass surrounding the optic nerve. OS: Vertical C/D ratio is 0.4. There are leopard spots temporal to the fovea. PHOTOS: The color photo in the right eye shows the white retinal mass and the left eye shows the leopard spots temporal to the fovea. SPECTRALIS-SD-OCT SCAN: The OCT scan through the macula in the right eye shows the mass to be intraretinal and in the left eye there are irregularities at the level of the pigment epithelium. FUNDUS PHOTOGRAPHY - AUTO FLUORESCENCE: The image in the right eye shows white hyper auto fluorescence centrally where the white reflective lesion is. In the left eye those little leopard spots are hyper auto fluorescencent. FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography in the right eye shows leakage from the area of retinal infiltrate. In the left eye there is hypo and hyper auto fluorescence corresponding to the leopard spots. INDOCYANINE GREEN ANGIOGRAPHY: The indocyanine green angiogram similarly shows the leopard spots in the left eye and leakage from the lesion in the right eye. IMPRESSION: 1. DIFFUSE CHORIORETINITIS – BOTH EYES 2. PROBABLE SYPHILITIC RETINITIS – RIGHT EYE AND CHOROIDITIS IN THE LEFT EYE 3. POSSIBLE OCULAR LYMPHOMA, TUBERCULOSIS, LYME DISEASE, AND GRANULOMATOUS CHOROIDITIS DISCUSSION: As I discussed on the phone with you, given the positioning FDABS and the classic signs in the retina for syphilis, I think even with the presence of a negative spinal tap, this is in all likelihood syphilitic choroiditis and retinitis and at the moment I don’t see the reason not to try an antibiotic treatment trial prior to other invasive testing. If he is on the appropriate treatment for neurosyphilis and he doesn’t show improvement within a week or two, then I don’t think there is any harm in doing vitreous biopsy in the right eye looking for PCR and for cytology and even for possible flow cytometry and then ultimately if that is negative, a retinal biopsy could be considered in the right eye, which may not have much visual potential depending on what happens to the optic nerve lesion. Visit 2: 02-06-13 74-year-old man was seen in the office on February 6, 2013. He has had decreasing vision in both eyes starting prior to his cataract surgery, which is in July of 2012. Since then he has had a sort of steady gradual downhill course, especially in the right eye, which unfortunately completely lost vision to no light perception not too long ago from possibly optic nerve related swelling, retinal vascular occlusion. His left eye unfortunately has continued inflammation. He has had vitrectomies as well as taps sent for his multiple tests. He has had PCR tests sent for toxoplasmosis and he has also had vitreous samples sent for possible lymphoma. Recently there is a suspicion he may have lymphoma. He was initially treated with a twenty one day course of penicillin, because of his positive FDABS and the possibility of syphilis. He was subsequently put on fluconazole forty one days of infusion and now he is getting IGG infusions. The right eye which was previously quite painful does feel a lot better now with the treatments. He has been on 20 mg of prednisone orally. His right eye now has fallen to no light perception. The left eye has some hazy vision. You were concerned about several things; one is mainly what possibilities there might be for diagnosis and therapy, especially to protect the left eye. VISUAL ACUITY: OD: NLP, OS 20/50. IOP: 13 OU. The right eye has some crystal cellular growth within the LASIK flap and the ReSTOR intraocular lens is in good position. The left eye has a ReSTOR intraocular lens in good position. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.1. There is neovascularization on the nerve. There are retinal hemorrhages in all four quadrants and the retinal arteries are narrow. OS: Vertical C/D ratio is 0.2. There is pigment mottling in the macula with sort of a leopard spot pattern of brown hyperpigmentation and superotemporal to the macula there is a whitish looking area of retinitis with an overlying retinal vessel, which looks to be involved with some either intra-arterial plaque or at least irritation of the vessel wall in a way that looks like it may be occlusive. COLOR PHOTOS: The color photos of the right eye do show retinal hemorrhage with some optic atrophy and a tuft of neovascularization around the nerve. The left eye the retinal vessels visible are clearly aggravated by the inflammation in the retina just superior temporal to the macula. FUNDUS PHOTOGRAPHY - AUTO FLUORESCENCE: The images show in both eyes a leopard spot pattern of hyperfluorescence scattered in the posterior pole. The right eye has a ring of hypofluorescence around the optic nerve with hyperfluorescence outside of that. FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography in the right eye shows florid neovascularization of the optic nerve with poor perfusion of the retinal arteries throughout the study. The pigment epithelium appears to be irregularly affected by the disease. There are some areas of hyperfluorescence and some areas of hypofluorescence scattered throughout the posterior pole. There are linear areas of hypofluorescence. I think all of that is left over from the time when he had the exudative detachment, which cleared with therapy. The left eye shows the leopard spot area of hyperfluorescence under the macula and superotemporally the area of whitening does have significant leakage. In the late frames the retinal vessels in that area do appear to still be perfused. That area superotemporally shows capillary dropout. INDOCYANINE GREEN ANGIOGRAPHY: In the right eye the linear areas of hypofluorescence are present, again looking like they are left over from the old retinal detachment and the neovascularization on the nerve is visible. The angiogram of the left eye, the areas of damage to the retinal vessel walls are more visible than they are on the fluorescein angiogram, but the underlying choroid looks reasonably healthy other than the areas of hypofluorescence corresponding to the leopard spots. SPECTRALIS-SD-OCT SCAN: The OCT scan of the left eye shows the leopard spot pigmentation. It looks like it is all in front of the retinal pigment epithelium. The OCT scan through the area of retinitis superotemporally shows full thickness retinal disorganization and swelling from the retinitis. IMPRESSION: 1. BILATERAL PAN UVEITIS 2. FOCAL POSTERIOR RETINITIS – LEFT EYE WITH AN AREA OF RETINAL VASCULITIS OVERLYING IT 3. LEOPARD SPOTS 4. RETINAL ARTERY AND VEIN OCCLUSION – RIGHT EYE RESULTING IN NO LIGHT PERCEPTION VISION DISCUSSION: I explained to the patient and his wife, at some length mostly that there is still unfortunately a diagnostic dilemma. It is unclear exactly what he has. The treatments of antibiotics combined with the steroids have made the eyes feel a lot better, which does suggest that there might have been an infectious ideology. My only concern is there is still an area of retinitis in the left eye despite what would seem to be adequate treatment for both syphilitic retinitis and for possible fungal issues. I told him at the moment the differential diagnoses include, infectious disease, auto immune disease and unfortunately neoplasm disease, because of the possible ocular lymphoma. Since it is still unclear exactly what he has, I think that the best thing to do at the moment is for him to see Janet Davis down in Miami for another opinion. This will be a third option and we talked to Janet Davis’s assistant and set that appointment up today for within the next two weeks. In the meantime, I am going to try make sure Dr. Davis has access to all the images that I have taken in the office. I appreciate you getting all the laboratory tests together and hopefully with that we will be able to come up with some sort of definitive plan as to any further diagnosis tests need to be done and any further treatment. I told him one extreme possibility would be to remove the right eye, since the right eye is no light perception vision and it is possible a pathologist would be able to examine it and help us decide whether this is infectious, auto inflammatory, neoplastic and to further narrow down the diagnosis to something which might allow us to treat and save the left eye.

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Uveitis - Retinitis - Vasculitis - possibly Syphilitis150 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis100 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis113 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis98 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis94 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis116 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis131 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis84 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis84 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis46 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis56 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis51 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis47 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis45 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis54 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis47 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis63 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis49 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis59 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis69 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis60 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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(0 votes)
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis50 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis49 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis48 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis37 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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(0 votes)
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis46 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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(0 votes)
maretinitis_uveitis_pefo1_12031227.jpg
Uveitis - Retinitis - Vasculitis - possibly Syphilitis54 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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(0 votes)
maretinitis_uveitis_pefo1_12031228.jpg
Uveitis - Retinitis - Vasculitis - possibly Syphilitis47 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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(0 votes)
maretinitis_uveitis_pefo1_12031229.jpg
Uveitis - Retinitis - Vasculitis - possibly Syphilitis38 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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(0 votes)
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis63 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63.
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye69 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye80 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye69 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye99 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye79 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye57 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye87 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye72 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye51 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye42 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye59 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye66 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye81 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye63 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye84 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye66 views00000
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye57 views00000
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Visit 1: 12-06-12 74-year-old man was seen in the office on December 3, 2012. He was doing fine until just a few months ago when he started noticing vision loss, first in the right eye than the left. Then the left eye had cataract surgery done back in July. He has noticed recently he is getting tired easily. He gets weak. He can’t walk for a long distance. He has lost five pounds within the last month and he also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. He does have a positive FTA-ABS, suggesting he might have syphilis, however, he had a spinal tap, which was negative. MRI initially revealed a mass lesion of the occipital lobe however repeat scanning with contrast showed the suspect area simply to be artifact. Further testing was ordered including lumbar puncture and blood testing which revealed a negative RPR, VDRL, Toxo titre, Cryptococcus and lyme titre. A vitreous sample (PPV) had negative PCR for lyme, toxo, HSV, HS and DNA for TP all of which were negative. VISUAL ACUITY: OD 1/200, OS 20/63. IOP: OD 14, OS 12. The right eye has 1+ cell and flare of the anterior chamber and a ReSTOR intraocular lens in good position. He also has corneal incisions. The left eye has a trace cell and flare of the anterior chamber and a ReSTOR intraocular lens in good position. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.2. There is a white intraretinal mass surrounding the optic nerve. OS: Vertical C/D ratio is 0.4. There are leopard spots temporal to the fovea. PHOTOS: The color photo in the right eye shows the white retinal mass and the left eye shows the leopard spots temporal to the fovea. SPECTRALIS-SD-OCT SCAN: The OCT scan through the macula in the right eye shows the mass to be intraretinal and in the left eye there are irregularities at the level of the pigment epithelium. FUNDUS PHOTOGRAPHY - AUTO FLUORESCENCE: The image in the right eye shows white hyper auto fluorescence centrally where the white reflective lesion is. In the left eye those little leopard spots are hyper auto fluorescencent. FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography in the right eye shows leakage from the area of retinal infiltrate. In the left eye there is hypo and hyper auto fluorescence corresponding to the leopard spots. INDOCYANINE GREEN ANGIOGRAPHY: The indocyanine green angiogram similarly shows the leopard spots in the left eye and leakage from the lesion in the right eye. IMPRESSION: 1. DIFFUSE CHORIORETINITIS – BOTH EYES 2. PROBABLE SYPHILITIC RETINITIS – RIGHT EYE AND CHOROIDITIS IN THE LEFT EYE 3. POSSIBLE OCULAR LYMPHOMA, TUBERCULOSIS, LYME DISEASE, AND GRANULOMATOUS CHOROIDITIS DISCUSSION: As I discussed on the phone with you, given the positioning FDABS and the classic signs in the retina for syphilis, I think even with the presence of a negative spinal tap, this is in all likelihood syphilitic choroiditis and retinitis and at the moment I don’t see the reason not to try an antibiotic treatment trial prior to other invasive testing. If he is on the appropriate treatment for neurosyphilis and he doesn’t show improvement within a week or two, then I don’t think there is any harm in doing vitreous biopsy in the right eye looking for PCR and for cytology and even for possible flow cytometry and then ultimately if that is negative, a retinal biopsy could be considered in the right eye, which may not have much visual potential depending on what happens to the optic nerve lesion. Visit 2: 02-06-13 74-year-old man was seen in the office on February 6, 2013. He has had decreasing vision in both eyes starting prior to his cataract surgery, which is in July of 2012. Since then he has had a sort of steady gradual downhill course, especially in the right eye, which unfortunately completely lost vision to no light perception not too long ago from possibly optic nerve related swelling, retinal vascular occlusion. His left eye unfortunately has continued inflammation. He has had vitrectomies as well as taps sent for his multiple tests. He has had PCR tests sent for toxoplasmosis and he has also had vitreous samples sent for possible lymphoma. Recently there is a suspicion he may have lymphoma. He was initially treated with a twenty one day course of penicillin, because of his positive FDABS and the possibility of syphilis. He was subsequently put on fluconazole forty one days of infusion and now he is getting IGG infusions. The right eye which was previously quite painful does feel a lot better now with the treatments. He has been on 20 mg of prednisone orally. His right eye now has fallen to no light perception. The left eye has some hazy vision. You were concerned about several things; one is mainly what possibilities there might be for diagnosis and therapy, especially to protect the left eye. VISUAL ACUITY: OD: NLP, OS 20/50. IOP: 13 OU. The right eye has some crystal cellular growth within the LASIK flap and the ReSTOR intraocular lens is in good position. The left eye has a ReSTOR intraocular lens in good position. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.1. There is neovascularization on the nerve. There are retinal hemorrhages in all four quadrants and the retinal arteries are narrow. OS: Vertical C/D ratio is 0.2. There is pigment mottling in the macula with sort of a leopard spot pattern of brown hyperpigmentation and superotemporal to the macula there is a whitish looking area of retinitis with an overlying retinal vessel, which looks to be involved with some either intra-arterial plaque or at least irritation of the vessel wall in a way that looks like it may be occlusive. COLOR PHOTOS: The color photos of the right eye do show retinal hemorrhage with some optic atrophy and a tuft of neovascularization around the nerve. The left eye the retinal vessels visible are clearly aggravated by the inflammation in the retina just superior temporal to the macula. FUNDUS PHOTOGRAPHY - AUTO FLUORESCENCE: The images show in both eyes a leopard spot pattern of hyperfluorescence scattered in the posterior pole. The right eye has a ring of hypofluorescence around the optic nerve with hyperfluorescence outside of that. FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography in the right eye shows florid neovascularization of the optic nerve with poor perfusion of the retinal arteries throughout the study. The pigment epithelium appears to be irregularly affected by the disease. There are some areas of hyperfluorescence and some areas of hypofluorescence scattered throughout the posterior pole. There are linear areas of hypofluorescence. I think all of that is left over from the time when he had the exudative detachment, which cleared with therapy. The left eye shows the leopard spot area of hyperfluorescence under the macula and superotemporally the area of whitening does have significant leakage. In the late frames the retinal vessels in that area do appear to still be perfused. That area superotemporally shows capillary dropout. INDOCYANINE GREEN ANGIOGRAPHY: In the right eye the linear areas of hypofluorescence are present, again looking like they are left over from the old retinal detachment and the neovascularization on the nerve is visible. The angiogram of the left eye, the areas of damage to the retinal vessel walls are more visible than they are on the fluorescein angiogram, but the underlying choroid looks reasonably healthy other than the areas of hypofluorescence corresponding to the leopard spots. SPECTRALIS-SD-OCT SCAN: The OCT scan of the left eye shows the leopard spot pigmentation. It looks like it is all in front of the retinal pigment epithelium. The OCT scan through the area of retinitis superotemporally shows full thickness retinal disorganization and swelling from the retinitis. IMPRESSION: 1. BILATERAL PAN UVEITIS 2. FOCAL POSTERIOR RETINITIS – LEFT EYE WITH AN AREA OF RETINAL VASCULITIS OVERLYING IT 3. LEOPARD SPOTS 4. RETINAL ARTERY AND VEIN OCCLUSION – RIGHT EYE RESULTING IN NO LIGHT PERCEPTION VISION DISCUSSION: I explained to the patient and his wife, at some length mostly that there is still unfortunately a diagnostic dilemma. It is unclear exactly what he has. The treatments of antibiotics combined with the steroids have made the eyes feel a lot better, which does suggest that there might have been an infectious ideology. My only concern is there is still an area of retinitis in the left eye despite what would seem to be adequate treatment for both syphilitic retinitis and for possible fungal issues. I told him at the moment the differential diagnoses include, infectious disease, auto immune disease and unfortunately neoplasm disease, because of the possible ocular lymphoma. Since it is still unclear exactly what he has, I think that the best thing to do at the moment is for him to see Janet Davis down in Miami for another opinion. This will be a third option and we talked to Janet Davis’s assistant and set that appointment up today for within the next two weeks. In the meantime, I am going to try make sure Dr. Davis has access to all the images that I have taken in the office. I appreciate you getting all the laboratory tests together and hopefully with that we will be able to come up with some sort of definitive plan as to any further diagnosis tests need to be done and any further treatment. I told him one extreme possibility would be to remove the right eye, since the right eye is no light perception vision and it is possible a pathologist would be able to examine it and help us decide whether this is infectious, auto inflammatory, neoplastic and to further narrow down the diagnosis to something which might allow us to treat and save the left eye.