Question of the Week

A 48-year-old woman with HIV presents with bilateral eye pain, photophobia, and tearing for one month. She started antiretroviral therapy 1 year ago. Her CD4 count is now about 250. Her visual acuity is 20/50 OD and 20/40 OS. On exam, her pupils are irregularly shaped, as seen in the image below. She has bilateral conjunctival injection, ciliary flush, anterior chamber cell and flare, large keratic precipitates, and posterior synechiae. A tuberculin skin test is positive.

Which of the following is the most appropriate initial management for this patient’s condition?

A. Oral antiviral therapy

B. Intravitreal antibiotics

C. Reassurance and observation

D. Topical steroids and cycloplegics

E. Emergent surgical management

Answer

The correct answer is D.

This patient has tuberculosis uveitis, likely unmasked after immune reconstitution following antiretroviral therapy. The most appropriate therapy is corticosteroid eyedrops for inflammation, cycloplegics to prevent further synechiation, along with treatment for the underlying tuberculosis. Antiviral therapy (choice A) could be used to treat herpetic uveitis, which is usually unilateral and non-granulomatous. Antibiotics (choice B) may be used for bacterial endophthalmitis, which presents with vision loss and vitritis, often caused by recent surgery or trauma. Reassurance and observation (choice C) is inappropriate, as untreated uveitis can lead to permanent vision loss. Surgery (choice E) is not indicated for uveitis.

Source: Doan A, Farjo A: TB Uveitis: 48-year-old African American female with complaint of photophobia, tearing, and eye pain in both eyes. February 21, 2005; Available from: http://www.EyeRounds.org/cases/case6.htm.