What the Cell Is That?

Anterior uveitis is the most common form of intraocular inflammation and can have multiple etiologies, including infectious, autoimmune, and idiopathic. Prompt recognition and management are crucial to avoid sequelae such as macular edema, cataracts, and glaucoma.¹ This case report includes an incidental finding of bilateral anterior uveitis in a patient with no significant ocular or systemic history, emphasizing the importance of systemic workups in atypical cases.

CASE PRESENTATION

A 41-year-old Indian female presented with pain OS for 2 days and constant blurry vision OU for 2 weeks. She had no previous ocular history, and her last physical examination 1 year prior was unremarkable. The patient’s medical history was notable for hypothyroidism, for which she was taking levothyroxine sodium. Her family history was not significant for ocular or systemic disease.

EXAMINATION

Upon examination, the patient’s BCVA was 20/20 OU. Her pupils were equal, round, and reactive to light without an afferent pupillary defect OU. Her IOP was 11 mm Hg OU. Anterior segment examination revealed no bulbar conjunctival injection OU. A cluster of punctate epithelial erosions was noted in the inferior midperipheral cornea OS. An extensive number of small and large keratic precipitates were noted on the corneal endothelium, 3+ white cells, and 1+ pigment cells in the anterior chamber OU, as well as a Koeppe nodule at the 10 clock position OS (Figure 1). Additionally, dilated posterior segment examination showed a clear vitreous without cells, normal macular contour, normal retinal vasculature without vasculitis, no retinal breaks, and cup-to-disc ratio of 0.45/0.45 OU (Figure 2).

DIFFERENTIAL DIAGNOSIS

Anterior Uveitis

The clinical presentation of keratic precipitates, cells in the anterior chamber, and a Koeppe nodule, as well as the absence of conjunctival injection, strongly suggested granulomatous anterior uveitis. This is typically associated with systemic conditions, such as sarcoid, lupus, syphilis, tuberculosis, rheumatoid arthritis, or HLA-B27–related inflammatory diseases.^2,3

Posterior Uveitis With Spillover

Although less likely, given the anterior segment findings, the possibility of posterior uveitis with spillover into the anterior chamber was considered. This condition typically presents with blurry vision and floaters.² Posterior involvement is assessed with further imaging and testing.

Posner-Schlossman Syndrome (Glaucomatocyclitic Crisis)

Because Posner-Schlossman syndrome is characterized by recurrent episodes of elevated IOP with mild anterior uveitis, we considered this diagnosis; however, the bilateral presentation and lack of episodic history made it unlikely.⁴

MANAGEMENT AND OUTCOME

The patient’s review of systems was negative for any skin rashes, lower back or joint pain, cough or shortness of breath, gastrointestinal pain, or pain with urination. She was prescribed cyclopentolate HCl 1% eye drops twice daily and prednisolone acetate 1% OU every 2 hours while awake. She was referred to her primary care physician for a systemic workup, including CBC with differential, antinuclear antibody test, angiotensin converting enzyme blood test, serum lysozyme, human leukocyte antigen typing (HLA-B27), rapid plasma reagin test, and fluorescent treponemal antibody absorption test, as well as rheumatoid factor and Lyme titers. The patient was also diagnosed with a resolving corneal abrasion OS, which was treated with ofloxacin drops four times daily OS. She was scheduled to follow up in 1 week.

The patient returned to the clinic 3 weeks later. She had been using cyclopentolate 1% twice daily, ofloxacin, and prednisolone acetate 1% four times daily OS, seen her primary care doctor, and completed all lab work, which was negative. Clinical examination revealed rare white cells OD and no anterior segment signs OS. She was told to start a slow taper of prednisolone acetate and discontinue use of cyclopentolate and ofloxacin. She was scheduled to follow up in 4 to 6 weeks; sooner with any problems.

DISCUSSION

A diagnosis of bilateral granulomatous anterior uveitis was made based on the slit-lamp finding of severe anterior chamber reaction OU. Granulomatous uveitis is inflammation of the uveal tract. Both infectious and noninfectious conditions can cause anterior uveitis. The exact pathophysiology of granulomatous uveitis depends on the underlying etiology. Granulomatous uveitis often presents with mutton fat keratic precipitates, anterior chamber cells and flare, anterior and/or posterior synechia, and elevated or decreased IOP.^1,5 It is critical to rule out systemic etiology so patients can be appropriately treated. Granulomatous uveitis requires a comprehensive approach to management, including prompt treatment to reduce inflammation and prevent sequelae.

This case illustrates the significance of early diagnosis and intervention, as well as the need for regular follow-up to monitor for recurrence or development of sequelae. With recurrence, more extensive workup should be considered, including chest X-ray, erythrocyte sedimentation rate test, polymerase chain reaction test, enzyme-linked immunoassay, and cerebrospinal fluid analysis.^3,5 Our patient’s prognosis is favorable, as her clinical signs resolved with topical treatment. In the case of reoccurrence, topical treatment should resolve ocular signs; if needed, systemic steroids, immunosuppressants, and biologics can be used as indicated.

BE SMART, ACT QUICK

Bilateral granulomatous anterior uveitis, although rare, usually signals the need for a thorough systemic evaluation.^1,3 Early and aggressive treatment is essential to prevent sequelae. This case underscores the importance of recognizing subtle clinical signs and maintaining a high index of suspicion for systemic diseases, even though up to 50% of uveitis cases are idiopathic.⁵