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Intermittent Temporal Visual Field Loss in a Middle-aged Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 45-year-old man presented with floaters in his left eye and headaches for 2 months. He experienced left temporal field loss when lifting heavy objects. He took no medications and denied prior surgery, eye trauma, or pain. His best-corrected visual acuity was 20/25 OD and 20/30 OS. The only abnormalities on bilateral eye examination were 1+ levels of anterior vitreous cells and trace levels of posterior vitreous cells in the left eye, without vitreous haze, and a left retinal detachment extending from 1:30 to 10:00 o’clock, with macular involvement and without visible retinal tears. There were 360° left choroidal detachments.

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Type 3 uveal effusion syndrome

B. Surgery to create scleral windows

Diagnostic vitrectomy with cytologic testing (choice A) would be appropriate for suspected primary vitreoretinal lymphoma with so-called leopard-spot lymphomatous infiltration under the retinal pigment epithelium, but there were few vitreous cells seen in this case. Choroidal thickening and exudation might occur in choroidal lymphoma, but this diagnosis would likely require tissue biopsy rather than vitreous biopsy.

Rhegmatogenous detachment should always be reconsidered when presumed exudative detachments do not resolve with initial treatment. Surgical repair with a scleral buckle (choice C) would then be appropriate. However, this patient had repeated fundus examinations and ultrasonographic images that did not reveal retinal tears. Also, there was no vitreous pigment and no stiffening of the retina.

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Article Information

Corresponding Author: Janet L. Davis, MD, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th St, Miami, FL 33136 (jdavis@med.miami.edu).

Published Online: July 11, 2019. doi:10.1001/jamaophthalmol.2019.1638

Conflict of Interest Disclosures: Dr Davis reports grants from Johns Hopkins, Eye Pharma, and Nightstar Therapeutics and personal consulting fees from Abbvie for participation in a steering committee and Allergan for participation in a data safety monitoring board, outside of the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
References
1.
Gass  JD.  Uveal effusion syndrome: a new hypothesis concerning pathogenesis and technique of surgical treatment.  Retina. 1983;3(3):159-163. doi:10.1097/00006982-198300330-00003PubMedGoogle ScholarCrossref
2.
Elagouz  M, Stanescu-Segall  D, Jackson  TL.  Uveal effusion syndrome.  Surv Ophthalmol. 2010;55(2):134-145. doi:10.1016/j.survophthal.2009.05.003PubMedGoogle ScholarCrossref
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Uyama  M, Takahashi  K, Kozaki  J,  et al.  Uveal effusion syndrome: clinical features, surgical treatment, histologic examination of the sclera, and pathophysiology.  Ophthalmology. 2000;107(3):441-449. doi:10.1016/S0161-6420(99)00141-4PubMedGoogle ScholarCrossref
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Ward  RC, Gragoudas  ES, Pon  DM, Albert  DM.  Abnormal scleral findings in uveal effusion syndrome.  Am J Ophthalmol. 1988;106(2):139-146. doi:10.1016/0002-9394(88)90825-2PubMedGoogle ScholarCrossref
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Shields  CL, Roelofs  K, Di Nicola  M, Sioufi  K, Mashayekhi  A, Shields  JA.  Uveal effusion syndrome in 104 eyes: response to corticosteroids—the 2017 Axel C. Hansen lecture.  Indian J Ophthalmol. 2017;65(11):1093-1104. doi:10.4103/ijo.IJO_752_17PubMedGoogle ScholarCrossref
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Johnson  MW, Gass  JD.  Surgical management of the idiopathic uveal effusion syndrome.  Ophthalmology. 1990;97(6):778-785. doi:10.1016/S0161-6420(90)32511-3PubMedGoogle ScholarCrossref
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Ozgonul  C, Dedania  VS, Cohen  SR, Besirli  CG.  Scleral surgery for uveal effusion.  Retina. 2017;37(10):1977-1983. doi:10.1097/IAE.0000000000001521PubMedGoogle ScholarCrossref
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