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Retinal Imaging Conference. Doug Sigford , M.D. University of Louisville Department of Ophthalmology and Visual Sciences 1/9/2014. Patient Presentation. CC : Routine diabetic eye exam

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retinal imaging conference
Retinal Imaging Conference

Doug Sigford, M.D.

University of Louisville

Department of Ophthalmology and Visual Sciences

1/9/2014

patient presentation
Patient Presentation

CC: Routine diabetic eye exam

HPI: 51 y/o white male without complaint presented for a routine diabetic eye exam. He had a 38 year history of type 1 diabetes mellitus, but no history of diabetic eye disease.

medical history
Medical History

POHx: Radial Keratotomy OS

PMH: DM, HIV, hyperlipidemia

CD4 944 cells/μl, viral load undetectable

Meds: Insulin, ezetimibe, atorvastatin, efavirenz,

fosamprenavir, raltegravir , ritonavir

Allergies: NKDA

ROS: Unremarkable, no recent illness

slide4

4mm

15

4mm

13

Exam

BCVA P TTP

EOM: Full OU

CVF: Full OU

Anterior Segment: unremarkable OU

20/20-3 (-1.00+0.50x65)

(-) RAPD

20/20-1 (+0.75 sphere)

color fundus photos
Color Fundus Photos

OD: Neurosensory detachment of the inferior macula including the fovea with underlying deep yellow lesions and RPE atrophy. Inferior cotton wool spots are also seen.

OS: Deep yellow lesions with areas of RPE atrophy

mosaic color photo os
Mosaic Color Photo OS

Large temporal chorioretinal scar

autofluorescence od
Autofluorescence OD

OD: Hyperautofluorescenceis seen in the periphery of the neurosensory detachment and patchy hypoautofluorescence is seen centrally.

autofluorescence os
Autofluorescence OS

OS: Mild perifovealhyperautofluorescence

oct o d
OCT OD

OCT through the fovea shows subretinal fluid, RPE disruption, and hyperreflective spots in the outer retina

oct o d1
OCT OD

OCT inferior to the fovea shows more subretinal fluid, CME, increased disruption of the RPE, and increased hyperreflective spots in the outer retina.

oct os
OCT OS

Small PED

fa icg od
FA/ICG OD

FA (right) shows early hyperfluorescence primarily in the central portion of the neurosensory detachment. ICG (left) shows both hyper- and hypofluorescence in the same area.

00:41

fa icg od late
FA/ICG OD (late)

FA (right) shows increased hyperfluorescence consistent with leakage and pooling. ICG (left) shows stable hyper- and hypofluorescence.

03:45

fa icg os
FA/ICG OS

FA (right) shows punctate areas of hyperfluorescence corresponding to the subretinal yellow lesions seen clinically. ICG (left) shows small hypofluorescent and hyperfluorescent areas.

01:01

fa icg os late
FA/ICG OS (late)

Late FA and ICG show stable macular features as well as the large temporal chorioretinal scar

03:16

assessment and plan
Assessment and Plan
  • A: 52yo WM with chorioretinitis OD > OS
    • Differential
      • Syphilis
      • TB
      • Lyme disease
      • Toxoplasmosis
      • Chronic central serous chorioretinopathy
  • P: Check RPR, FTA-ABS, Toxoplasma titers, PPD
follow up
Follow-Up
  • RPR 1:1 (previously nonreactive)
  • FTA-ABS positive
  • Plan
    • The patient’s primary doctor was notified and a PICC line was placed for a 2 week course of IV penicillin
follow up1
Follow-Up

2 week follow-up showed decreased subretinal fluid

Initial OCT

Follow-up

syphilis
Syphilis
  • Infection caused by the spirochete Treponemapallidum
  • Occurs in four stages (plus congenital):
    • Primary – characterized by a skin lesion (chancre) at the point of contact with regional lymphadenopathy
    • Secondary – four to ten weeks after primary infection, most commonly involves skin, mucous membranes, and lymph nodes
    • Latent
    • Tertiary – gummatous, neurosyphilis, or cardiovascular
ocular syphilis
Ocular Syphilis
  • May affect all structures of the eye
  • The most common ocular finding in both secondary and tertiary syphilis is uveitis
    • Iridocyclitis
    • Posterior Uveitis
      • Focal or diffuse necrotizing retinitis
      • Punctate inner retinitis
      • Vasculitis
      • Posterior placoidchorioretinitis
      • Serous or exudative retinal detachment
    • Keratouveitis
syphilis stages
Syphilis - Stages
  • Infection caused by the spirochete Treponemapallidum
  • Occurs in four stages (plus congenital):
    • Primary – characterized by a skin lesion (chancre) at the point of contact with regional lymphadenopathy
    • Secondary – four to ten weeks after primary infection, most commonly involves skin, mucous membranes, and lymph nodes
    • Latent
    • Tertiary – gummatous, neurosyphilis, or cardiovascular
syphilis diagnosis
Syphilis - Diagnosis
  • Nontreponemal tests
    • Moderate sensitivity, low specificity
    • Rapid plasma reagin (RPR)
    • Venereal disease research laboratory (VDRL)
    • Detect anti-cardiolipin antibodies through their interaction with diphosphatidyl glycerol
    • Can be used to monitor therapy and reactivation
syphilis diagnosis1
Syphilis - Diagnosis
  • Treponemal tests
    • High specificity
    • FTA-Abs
    • TPPA (treponemapallidum particle agglutination assay)
    • Remain positive for life
syphilis treatment
Syphilis - Treatment
  • Uncomplicated
    • Single dose IM penicillin G or oral azithromycin
  • Neurosyphilis
    • IV penicillin for 10 – 14 days
    • Lumbar puncture is recommended
references
References

1. Mattei PL, Beachkofsky TM, Gilson RT, Wisco OJ. Syphilis: a reemerging infection. Am Fam Physician. 2012 Sep 1;86(5):433-40.

2. Aldave AJ, King JA, Cunningham ET Jr. Ocular syphilis. CurrOpinOphthalmol. 2001 Dec;12(6):433-41.

3. Wilhelmus K, Lukehart S: Syphilis. In Ocular Infection and Immunity. Edited by Pepose J, Holland G, Wilhelmus K: Mosby; 1996:1437–1466. 

4. Gaudio PA. Update on ocular syphilis. CurrOpinOphthalmol. 2006 Dec;17(6):562-6.

5. Tamesis RR, Foster CS. Ocular syphilis. Ophthalmology 1990; 97:1281–1287.

6. Hughes EH, Guzowski M, Simunovic MP, Hunyor AP, McCluskey P. Syphilitic retinitis and uveitis in HIV-positive adults. Clin Experiment Ophthalmol. 2010 Dec;38(9):851-6. doi: 10.1111/j.1442-9071.2010.02383.x.

7. Kunkel J, Schürmann D, Pleyer U, et al. Ocular syphilis—indicator of previously unknown HIV-infection. J Infect 2009; 58:32–36.

8. Lynn WA, Lightman S. Syphilis and HIV: a dangerous combination. Lancet Infect Dis. 2004 Jul;4(7):456-66.