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A Boy With Anterior Uveitis and Optic Disc Swelling

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

A 14-year-old boy was referred to us because of ocular and periocular pain with photophobia in his right eye for the last 5 days. Aside from atopic dermatitis, his medical history was unremarkable. Best-corrected visual acuity was 20/20 OU. Slitlamp examination of the right eye disclosed conjunctival hyperemia and ciliary congestion, anterior chamber flare 2+, and a few nongranulomatous keratic precipitates; the left anterior segment was quiet. Intraocular pressure was 15 mm Hg OU. Pupillary light responses were normal. Dilated fundus examination revealed 1+ of vitritis (binocular indirect ophthalmoscopy score) in the right eye and swelling of the optic disc in both eyes, to a greater extent in the right eye (Figure, A). Routine blood tests, including full blood cell count, plasma glucose levels, liver function test, and kidney function test, were performed on the same day and showed a serum creatinine level of 1.57 mg/dL (reference range: 0.5-1.0 mg/dL; to convert to micromoles per liter, multiply by 88.4). Antibodies anti–Treponema pallidum were tested and the results were negative.

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Tubulointerstitial nephritis and uveitis syndrome

B. Order urinalysis and urinary β2-microglobulin test

Starting topical treatment with corticosteroids and cycloplegic eye drops without further investigations (choice A) would not be the preferred answer because abnormal kidney function warrants further investigations. Indeed in this case, urinalysis and urinary β2-microglobulin (β2M) testing (choice B) revealed normoglycemic glycosuria and increased β2M levels (6.6 mg/24 h; reference range, 0.02-0.37), suggestive of tubulointerstitial nephritis and uveitis syndrome (TINU).1 Magnetic resonance imaging (MRI) of the brain and orbits (choice C) was not indicated as urgent investigation, because the observed optic disc edema was most likely secondary to the intraocular inflammation rather than a central nervous system dysfunction. However, MRI of the brain and orbits was performed electively and did not show any abnormalities. Finally, observation (choice D) in symptomatic and active uveitis is not recommended.

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Article Information

Corresponding Author: Giuseppe Casalino, MD, Oftalmico Hospital, ASST Fatebenefratelli Sacco, Piazza Principessa Clotilde n.3, 20121 Milan, Italy (peppecasalino@gmail.com).

Published Online: September 23, 2021. doi:10.1001/jamaophthalmol.2021.1056

Conflict of Interest Disclosures: None reported.

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

References
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2.
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Pakzad-Vaezi  K , Pepple  KL .  Tubulointerstitial nephritis and uveitis.   Curr Opin Ophthalmol. 2017;28(6):629-635. doi:10.1097/ICU.0000000000000421 PubMedGoogle ScholarCrossref
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Saarela  V , Nuutinen  M , Ala-Houhala  M , Arikoski  P , Rönnholm  K , Jahnukainen  T .  Tubulointerstitial nephritis and uveitis syndrome in children: a prospective multicenter study.   Ophthalmology. 2013;120(7):1476-1481. doi:10.1016/j.ophtha.2012.12.039PubMedGoogle ScholarCrossref
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