[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.206.194.83. Please contact the publisher to request reinstatement.
[Skip to Content Landing]

A Woman With Bilateral Retinal Detachments

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

A 33-year-old otherwise healthy black woman presented to the emergency department for evaluation of blurry vision in both eyes. She had no relevant medical, family, or ocular history. There was no history of trauma or ocular surgery. One month prior to presentation, she had developed fevers, chills, and coughing. After several days, she had developed redness, pain, photophobia, and blurry vision in her left eye, and she had subsequently developed similar symptoms in her right eye. On presentation, her visual acuity was counting fingers OU. Intraocular pressures were 14 mm Hg OU. A slitlamp examination revealed mild conjunctival redness, 2+ anterior chamber cell, and flare in both eyes, as well as mild posterior synechiae. The cornea was clear without keratic precipitates, and there were no iris nodules. Pigment was present on the anterior lens capsule. A fundus examination demonstrated a moderate amount of vitreous cell, hyperemia and edema of the optic disc, and retinal detachments in both eyes (Figure). The detachments were inferior and shifted with the patient’s head position, suggesting serous detachments. Findings were similar bilaterally. A B-scan ultrasonographic test demonstrated bullous retinal detachments and diffusely thickened choroid.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Vogt-Koyanagi-Harada disease

B. Quantiferon and rapid plasma reagin tests and chest radiography

The patient underwent a systemic workup, including chest radiography and serum testing for quantiferon gold and rapid plasma reagin (choice B) as well as treponemal antibodies, which were all unremarkable. Given the negative results of the workup, the patient’s presentation was consistent with probable Vogt-Koyanagi-Harada (VKH) disease.

Intravitreal triamcinolone injections (choice A) would not be the preferred next step because, while VKH disease is most likely, it is important to rule out infectious causes of panuveitis first, especially prior to local steroid treatments. Furthermore, systemic and not intravitreal steroids would be the preferred route.1

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Levi N. Kanu, MD, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 1855 W Taylor St, Ste 1.145 (MC 648), Chicago, IL 60612 (levi.kanu@gmail.com).

Published Online: September 5, 2019. doi:10.1001/jamaophthalmol.2019.3086

Conflict of Interest Disclosures: None reported.

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

References
1.
Read  RW.  Vogt-Koyanagi-Harada disease.  Ophthalmol Clin North Am. 2002;15(3):333-341. doi:10.1016/S0896-1549(02)00025-1PubMedGoogle ScholarCrossref
2.
Shindo  Y, Ohno  S, Yamamoto  T, Nakamura  S, Inoko  H.  Complete association of the HLA-DRB1*04 and -DQB1*04 alleles with Vogt-Koyanagi-Harada’s disease.  Hum Immunol. 1994;39(3):169-176. doi:10.1016/0198-8859(94)90257-7PubMedGoogle ScholarCrossref
3.
Weisz  JM, Holland  GN, Roer  LN,  et al.  Association between Vogt-Koyanagi-Harada syndrome and HLA-DR1 and -DR4 in Hispanic patients living in Southern California.  Ophthalmology. 1995;102(7):1012-1015. doi:10.1016/S0161-6420(95)30920-7PubMedGoogle ScholarCrossref
4.
Chan  C-C, Wallace  DJ.  Intraocular lymphoma: update on diagnosis and management.  Cancer Control. 2004;11(5):285-295. doi:10.1177/107327480401100502PubMedGoogle ScholarCrossref
5.
Read  RW, Holland  GN, Rao  NA,  et al.  Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: report of an international committee on nomenclature.  Am J Ophthalmol. 2001;131(5):647-652. doi:10.1016/S0002-9394(01)00925-4PubMedGoogle ScholarCrossref
6.
Damico  FM, Cunha-Neto  E, Goldberg  AC,  et al.  T-cell recognition and cytokine profile induced by melanocyte epitopes in patients with HLA-DRB1*0405-positive and -negative Vogt-Koyanagi-Harada uveitis.  Invest Ophthalmol Vis Sci. 2005;46(7):2465-2471. doi:10.1167/iovs.04-1273PubMedGoogle ScholarCrossref
7.
Sugita  S, Takase  H, Taguchi  C,  et al.  Ocular infiltrating CD4+ T cells from patients with Vogt-Koyanagi-Harada disease recognize human melanocyte antigens.  Invest Ophthalmol Vis Sci. 2006;47(6):2547-2554. doi:10.1167/iovs.05-1547PubMedGoogle ScholarCrossref
8.
Lai  TYY, Chan  RPS, Chan  CKM, Lam  DSC.  Effects of the duration of initial oral corticosteroid treatment on the recurrence of inflammation in Vogt-Koyanagi-Harada disease.  Eye (Lond). 2009;23(3):543-548. doi:10.1038/eye.2008.89PubMedGoogle ScholarCrossref
9.
Sheu  S-J, Kou  H-K, Chen  J-F.  Prognostic factors for Vogt-Koyanagi-Harada disease.  J Chin Med Assoc. 2003;66(3):148-154.PubMedGoogle Scholar
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Topics
State Requirements