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Diffuse Berlin nodules: unusual presentation of ocular sarcoidosis
  1. Enoch Kassa1,
  2. Victor M Elner2,
  3. Sayoko E Moroi2,
  4. Yang Sun1
  1. 1Glick Eye Institute, Ann Arbor, Michigan, USA
  2. 2Indianapolis, IN and Kellogg Eye Center, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Yang Sun, Department of Ophthalmology, Glick Eye Institute, Indiana University School of Medicine, 1160 West Michigan Street, Indianapolis, IN 46202, USA; sunyo{at}

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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 1A, arrow). More nodules were visible in the anterior chamber angle by gonioscopy (figure 1B, 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.

Figure 1

Slit-lamp examination showing anterior synechiae and abnormal white lesions on the peripheral iris at the iris–sclera junction (arrow, A). A closer gonioscopic look showing white nodules at the anterior chamber angle (arrow head, B). Access the article online to view this figure in colour.

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 …

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  • Contributors All four authors were involved in preparing the manuscript.

  • Competing interests None.

  • Ethics approval This is a case study with anonymity fully kept.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Final diagnosis Ocular sarcoidosis with Berlin nodules.