CASE OF THE MONTH: Q2 2025

A great case of something

Akshay Thomas, MD, MS, FASRS – Tennessee Retina

Chief complaint

  • 50-year-old Caucasian gentleman with progressive decline in vision OU over the last 2 weeks

History

  • Social History: Policeman, no IVDU
  • PMH: None
  • Medications: None
  • ROS: Shingles as a child

Examination

  • VA: 20/40 ecc OD, 20/20 OS
  • IOP: 12 OD, 9 OS
  • Pupils: Round and reactive
  • Motility: normal OU
  • Cornea/AC: Rare cell in AC OU
  • Anterior Vitreous: 1+ cells OU


Summary

  • Occlusive retinal vasculitis
  • Normal choroidal blood flow
  • Involves both arterioles and venules

Differential?

  • Retinal vasculitis
  • Arteritis vs phlebitis vs both
  • Large vessel vs small vessel involvement
  • Occlusive vs non-occlusive
  • Arteritis vs phlebitis vs both
  • Large vessel vs small vessel involvement
  • Occlusive vs non-occlusive

Retina vasculitis – Things to look for

  • Laterality
  • Phlebitis vs arteritis
  • Frosted branch angiitis
  • Occlusive vs non-occlusive
  • Retinal whitening
  • Family History
  • Ocular History
  • Retinitis
  • Systemic symptoms*
  • Unilateral: Toxoplasmosis, viral
  • Predominantly phlebitis: Sarcoidosis, MS, Behçet’s
  • Predominantly arteritis: Susac, ANCA-associated, SLE
  • Frosted branch angiitis: Viral, ANCA-associated
  • Family History: ADNIV, TREX1-associated
  • Ocular History: HORV, brolucizumab-related
  • Retinitis: INFECTIOUS, Behçet’s
  • Systemic symptoms: Numerous

Next Steps?

  • Aqueous tap for viral PCR
  • Bilateral intravitreal foscarnet injections
  • Bilateral PRP
  • Etiologic testing
  • Empiric antivirals
  • Oral steroids

Etiologic Testing

All negative!


Next Steps

  • Course of oral steroids – monitor for stabilization vs progression
  • Steroid sparing immunosuppression initiated: Methotrexate plus Adalimumab

Continued vascular pruning when prednisone tapered below 20 mg


Next Steps

  • Humira increased to weekly, Methotrexate 25 mg weekly continued, bilateral ozurdex
  • Subsequently switched to Remicade 10 mg/kg q4 weeks, injected bilateral fluocinolone acetonide implants
  • Now off oral steroids and stable without progression for 3 months

Disclosures

  • Alimera/ANI (C)
  • Allergan (C)
  • Avesis (C)
  • Bausch + Lomb (C)
  • Eyepoint (C)
  • Genentech (C, SB)
  • Regeneron (C)
  • Zeiss (C)