Manfred Zierhut Manfred Zierhut Centre of Ophthalmology University of Tuebingen, Germany Masquerade Syndrome

Refering Letter – Ocular History  30 year old female white patient  March 2004:  OU „therapy-resistant chorioretinitis“  2004:  10 days hospitalized at a department of Ophthalmology

Refering Letter – Ocular Examination  VA: OU 1.0,  anterior segment: OU: regular  fundus:  OD: optic disc vital, chorioretinal infiltrations at the upper and lower vessel arc, without activity, macula regular  OS: less infiltrations, no activity, macula regular

Previous Diagnostics  routinelab: unremarkable  ESR: 19/38mm  protein electrophoresis: α2- and ß-globuline minimally above the normal range  ACE normal, ANA negative  hepatitis-B and hepatitis-C negative  HIV 1 and 2 negative  CMV, Picorna/ECHO, VZV, measles virus, mumps virus, HSV 1 and 2, FSME virus, coxsackie virus: no signs for active infection

Previous Diagnostics  Candida albicans serology: negative  Toxocara canis serology: negative  Toxoplasma gondii serology: negative  Yersinien-Serology: no sign for acute infection  Lyme disease serology: no sign for acute infection  Lues-serology: negative  Anti-Streptolysin O: negative  HLA B 27 positiv, HLA DR11, DR17

Refering Letter „Under treatment with oral prednisolone at the hospital reduction of the size of the lesions, with better demarcation“ „Under treatment with oral prednisolone at the hospital reduction of the size of the lesions, with better demarcation“ „During close follow ups again more chorioretinal lesions after reduction of the corticosteroids“ „During close follow ups again more chorioretinal lesions after reduction of the corticosteroids“ rheumatologist suggested additionally azathioprine (since ) rheumatologist suggested additionally azathioprine (since )

First Presentation – Ocular Examination Since 6 weeks white spots in both eyes, esp during work on the computer, since 3 weeks elevated blood pressure detected (170/90mmHg) Since 6 weeks white spots in both eyes, esp during work on the computer, since 3 weeks elevated blood pressure detected (170/90mmHg) Ocular history: CL since the age of 18, foreign body injury (?) Ocular history: CL since the age of 18, foreign body injury (?)

First Presentation – Ocular Examination VA OU 1.0, VA OU 1.0, IOP: OU 18mmHg IOP: OU 18mmHg Anterior segment: OU no endothelial precipitates, no AC cells, pupil round, lens clear, mild vitreous body destruction, but no vitreos cells Anterior segment: OU no endothelial precipitates, no AC cells, pupil round, lens clear, mild vitreous body destruction, but no vitreos cells

First Presentation – General History  sakroileitis

First Presentation Treatment at this moment  Prednisolon 15mg,  Azathioprine 100mg

First Presentation – Ocular Examination Fundus OD optic disc with mild edema nasally, vital optic disc with mild edema nasally, vital macula dry macula dry white retinal infiltrations around the vessel arcs white retinal infiltrations around the vessel arcs narrow arteries, tortuositas of the vessels narrow arteries, tortuositas of the vessels size variations of the venes size variations of the venes crossing signs crossing signs mild retinal point bleedings mild retinal point bleedings regular periphery regular periphery

First Presentation – Ocular Examination Fundus OS optic disc with clear demarcation, vital, slightly hyperemic optic disc with clear demarcation, vital, slightly hyperemic macula dry macula dry white retinal infiltrations around the vessel arcs white retinal infiltrations around the vessel arcs narrow arteries, tortuositas of the vessels narrow arteries, tortuositas of the vessels size variations of the venes size variations of the venes crossing signs crossing signs mild retinal point bleedings mild retinal point bleedings regular periphery regular periphery

First Presentation – Fundus OS

Diagnosis  Hypertensive Retinopathy  based on  clinical findings  course of the disease  missing response to anti-inflammatory treatment  in addition: HLA-B27 positive ankylosing spondylitis without uveitis

Conclusion  retinopathy of arterial hypertension may look like uveitis for the first view  cotton wool spots are highly typical  no cellular infiltration of the vitreous or anterior chamber are detectable  highly important to differentiate the layer of lesions: retinal vs chorioretinal  too much lab investigation does not clarify the situation, may even lead to a wrong diagnosis