Download PDF

Make your diagnosis in the comments, and look for the answer in next month’s Blink.

Last Month’s Blink

An Unusual Presentation of Sarcoidosis

Written by Rachel H. Lee, MD, MPH, Jerome Giovinazzo, MD, Richard M. France, MD, and Stephanie Llop, MD, New York Eye and Ear Infirmary of Mount Sinai. Photo by Medical Photography Department at New York Eye and Ear Infirmary of Mount Sinai.

A 29-year-old man with a history of chronic cough, pleuritic chest pain, night sweats, and multiple hospitalizations for pneu­monia presented with a one-day history of sud­den-onset decreased vision in his left eye. He also had a history of working in methadone clinics, and his tuberculosis status was unknown.

His visual acuity was 20/20 in the right eye and counting fingers at 3 inches in the left. Examina­tion revealed 1+ vitreous cells and perivenous sheathing in his right eye (Fig. 1). In his left eye, 2+ vitreous cells, large preretinal vitreous hem­orrhage overlying the macula and surrounding the optic nerve, intraretinal dot-and-blot hemor­rhages, and perivenous sheathing in the periph­eries were evident (Fig. 2). The right fluorescein angiography demonstrates hyperfluorescence of the optic nerve and late leakage of the peripheral vessels (Figs. 3, 4).

Initial workup was significant for indetermi­nate Quantiferon Gold testing and elevated levels of angiotensin-converting enzyme. Chest X-ray and computed tomography revealed bilateral hi­lar lymphadenopathy and a 5-mm nodule in the right lower lobe of the lung. Syphilis, HLA-B27, Lyme disease, and antineutrophil cytoplasmic an­tibody tests were negative. The patient’s pulmo­nologist eventually performed a lung biopsy, and the findings were consistent with sarcoidosis.

Patients with ocular sarcoidosis often present with uveitis; retinopathy and vitreous hemor­rhage constitute rare clinical presentations of the disease. This case illustrates the importance of considering sarcoidosis as an etiology of vitreous hemorrhage in the setting of posterior uveitis.

Read your colleagues’ discussion.