MY-OH-MY Just a Drop will Do

A 45-year-old man presented with progressive loss of vision. Six months prior, he underwent cataract surgery in both eyes with subsequent development of refractory inflammation and intraocular pressures greater than 40 mmHg despite maximal medical therapy. He underwent bilateral trabeculectomies, scarring secondary to persistent inflammation and necessitating the placement of ahmed valves bilaterally. His intraocular inflammation was managed with topical and oral steroids and he was referred to uveitis who began an extensive work-up for this refractory inflammation. The patient endorsed headaches, depression, forgetfulness, low libido and weight loss. His medical history was unremarkable except for undercooked pork consumption monthly and travel to Mexico 5 years prior. On examination, the patient was somnolent and responded slowly. He had continuous hiccups and chewing movements of his mouth. His visual acuity was 20/80 OD and count fingers at 1 foot OS. Pupils were fixed and poorly reactive. His eye movements had partial limitation in all directions of gaze and extremely slow saccades. Anterior segment examination demonstrated moderate keratic precipitates bilaterally and diffuse anterior segment inflammation (Figure 1). Posterior segment examination demonstrated vitreous cell bilaterally with significant cupping and pallor of his optic nerves and scattered macular exudates. (Figure 2). Cranial nerve, motor and sensory examinations were normal. Optical coherence tomography of the retina demonstrated preretinal precipitates (Figure 3). MRI revealed bilateral optic nerve atrophy and an 8-mm enhancing hypothalamic/infundibular nodule with infiltration along the inferior aspect of the optic chiasm (Figure 4). Endocrine serology was notable for a slightly elevated prolactin (46.2 μg/L [normal range, 2.0 to 18.0 μg/L]). Serologic interferon-Ɣ, Lyme antibody, treponemal antibody, and rapid plasma reagin were all negative. Chest radiography was normal. Cerebrospinal fluid analysis demonstrated normal (4) white cells with 10% neutrophils, protein, glucose and no oligoclonal banding and negative cultures. A diagnostic test was then performed.