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TD Myers, JR Smith, AK Lauer, JT Rosenbaum; Diagnosis of Metastatic Infection in Patients Presenting with Uveitis and Iris Nodules . Invest. Ophthalmol. Vis. Sci. 2002;43(13):4262.
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Purpose: The presence of nodules on the iris is an infrequent, but well-recognized clinical sign in uveitis. The diseases most commonly associated with iris nodules include sarcoidosis, Fuchs' heterochromic iridocyclitis, Vogt-Koyanagi-Harada syndrome, multiple sclerosis and metastatic infection. In contrast to the treatment of non-infectious uveitis, which involves immunosuppressive medication, the management of infectious uveitis is intensive antimicrobial therapy. Inappropriate immunosuppressive therapy may result in a poor outcome for the patient with an infectious etiology. Consequently, we wanted to identify clinical features that could differentiate infection from non-infectious inflammation in patients presenting with uveitis and iris nodules. Methods: We retrospectively reviewed the clinical database of all consecutive patients evaluated at a tertiary care referral-based North American uveitis clinic between September 1985 and November 2001 to identify cases of infectious uveitis with iris nodules. For these cases, we recorded details of the clinical presentation, including ocular and systemic history and ocular examination. A MEDLINE search was performed to identify additional cases, and collect similar information. Results: Of approximately 1700 patients examined over 16 years at our uveitis service, we identified 3 cases of infectious uveitis with iris nodules. All cases were referred to the service with the diagnosis of noninfectious uveitis. In each case, an infectious etiology was confirmed by uncomplicated anterior chamber paracentesis, followed by culture of aqueous humor. Candida albicans, a Corynebacterium species and an Actinobacillus species were isolated from the 3 eyes, respectively. An additional 25 cases of infectious uveitis with iris nodules were identified in 22 published reports. Analysis of our cases and these reports showed that infectious uveitis with iris nodules was specifically characterized by (1) creamy, soft appearance to the nodule(s), (2) rapid growth of the nodule(s) despite corticosteroid therapy, (3) marked inflammatory response in the anterior chamber and/or vitreous humor, and/or (4) history suggesting a potential source of septic emboli. Conclusion: Certain features of the clinical history and examination are useful in the diagnosis of metastatic infection in patients presenting with uveitis and iris nodules. Anterior chamber paracentesis is a safe and effective method for obtaining a microbiological specimen to confirm the diagnosis.
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