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An adult patient was sent to Kellogg Eye Center by an optometrist for a 3-month history of gradual blurry vision in the right eye. The optometrist reported abnormalities during slit-lamp examination in the right eye. The left eye was unaffected. The patient denied pain in either eye. The patient is overall healthy without any pertinent past medical or surgical history. On examination, visual acuity was 20/40 in the affected eye and 20/25 in the left eye. General physical exam was otherwise unremarkable. Pupillary examination showed a mild afferent pupillary defect in the right eye.
Schirmer I test was within normal limits with 15 mm in right eye and 14 mm in left eye. Intraocular pressure (IOP) was elevated to 34 mm Hg in the right eye while the left eye was normal with 16 mm Hg. Whitish nodules were observed against the peripheral cornea by slit-lamp examination ( figure 1 A, arrow). More nodules were visible in the anterior chamber angle by gonioscopy ( figure 1 B, arrowhead) with superficial fine vessels; peripheral anterior synechiae (PAS) was not observed. Dilated fundoscopic examination was normal and examination of the tarsal conjunctiva did not reveal granuloma formation.
Imaging and laboratory studies including CBC, chest x-ray, RPR/VDRL, antitreponemal antibody test, ACE levels, lysozyme levels and CT of orbit were all negative. The patient was then scheduled for a biopsy of the ocular lesions. Biopsy was performed and the specimen was sent to the pathology laboratory. Pathology report identified non-granulomatous giant-cells consistent with sarcoidosis ( figure 2 ).
The patient was treated with topical corticosteroids and followed up weekly for several weeks until vision and IOP returned to within normal levels.
Questions
What are Berlin nodules?
What is the differential diagnosis for nodules found in the angle of the iris?
What are the different manifestations of ocular sarcoidosis?
For answers see 1223
Answers (For questions see 1214)
What are Berlin nodules?
What is the differential diagnosis for nodules found in the angle of the iris?
Ocular nodules may be found in several conditions including malignancies, syphilis, tuberculosis and sarcoidosis. Most of these diseases present with systemic symptoms and require laboratory tests and imaging to assist in formulating an appropriate differential diagnosis.
Malignancies such as lymphomas, leukaemias, melanomas...