This is an example of a conversation with “LUCIA,” a customized ChatGPT.

You said:

hello

Ophthalmology Sim Patient Creator said:

Hello, on which topic would you like me to create a simulated patient for you to work on today? If you're not sure, you may want to get inspiration on the case you want to present at https://eyewiki.org/Category:Articles. The list is only for inspiration. No content is uploaded to ChatGPT.

You said:

a case on sarcoidosis uveitis

Ophthalmology Sim Patient Creator said:

Thank you. I will create a simulated patient case with sarcoid uveitis as the underlying diagnosis.

Would you like me to:

  1. Present the entire case at once, so you can decide how and when to present it to your residents,
    or

  2. Present the case step by step, encouraging your residents to suggest differential diagnoses and next steps as we go?

Please choose your preferred format.

You said:

step by step

Ophthalmology Sim Patient Creator said:

Excellent — we will proceed step by step. I will guide the case in a way that allows your residents to explore differential diagnoses and suggest appropriate next steps in the workup.

🔒 Reminder: I will never reveal the final diagnosis unless you specifically request it.

✅ The case is prepared to be presented to your residents.
Have them answer my questions, and I will continue presenting the case.
I recommend you do not share the screen with your residents, as I may inadvertently disclose the diagnosis.

🧑‍⚕️ Initial Patient Presentation:

A 45-year-old African-American female presents to your clinic with the main complaint of blurry vision and redness in her right eye for the past 3 weeks.

How would your residents proceed from here?
Let them suggest:

  • Possible differential diagnoses, and

  • What they would like to ask in the history or do next.

I’m ready for their answers.

You said:

History, Visual acuity, slitlamp, fundus examination

Ophthalmology Sim Patient Creator said:

Excellent — we’ll proceed step by step through:

  1. History

  2. Visual acuity

  3. Slit-lamp exam (anterior segment)

  4. Fundus examination

Let’s begin with the history.

📋 Detailed History:

  • Onset: Symptoms began gradually about 3 weeks ago.

  • Laterality: Unilateral (right eye).

  • Symptoms: Blurry vision, eye redness, mild photophobia, occasional floaters. No significant ocular pain.

  • Systemic symptoms:

    • Mild dry cough for a few months.

    • Occasional shortness of breath on exertion.

    • No fever or weight loss.

  • Past ocular history: No history of trauma, ocular surgery, or prior uveitis.

  • Medical history: Hypertension, well-controlled.

  • Family history: No family history of autoimmune or ocular diseases.

  • Medications: Lisinopril.

  • Allergies: None known.

  • Social history: Non-smoker. Works as a school teacher.

Would you like to interpret the history with your residents now, or shall we proceed directly to visual acuity findings?

You said:

visual findings

Ophthalmology Sim Patient Creator said:

Here are the findings from the visual acuity assessment:

👁️ Visual Acuity:

  • Right eye (OD): 20/80 (pinhole improves to 20/50)

  • Left eye (OS): 20/20

  • Near vision: J5 OD, J1 OS

  • No relative afferent pupillary defect (RAPD) noted.

Would you like to interpret these findings and adjust your differential with your residents, or shall we proceed to the slit-lamp examination?

You said:

slitlamp

Ophthalmology Sim Patient Creator said:

Here are the findings from the slit-lamp examination of both eyes:

🔬 Slit-Lamp Examination:

Right Eye (OD):

  • Conjunctiva: Mild injection, especially in the perilimbal region.

  • Cornea: Fine keratic precipitates (KPs) scattered across the endothelium; some appear mutton-fat in morphology.

  • Anterior chamber: 2+ cells, 1+ flare.

  • Iris: No synechiae or nodules observed.

  • Lens: Early posterior subcapsular changes noted.

  • Intraocular Pressure (IOP): 16 mmHg

Left Eye (OS):

  • Normal anterior segment.

  • IOP: 14 mmHg

📌 Would you like to discuss differential diagnoses with your residents based on these anterior segment findings, or proceed to the fundus examination?

You said:

uveitis

Ophthalmology Sim Patient Creator said:

Good — your residents are thinking along the right lines by identifying uveitis as a key feature here.

Let’s move forward with the fundus examination, which will help further narrow down the differential and assess posterior involvement.

🔍 Fundus Examination:

Right Eye (OD):

  • Vitreous: 2+ vitritis (hazy view of the posterior pole).

  • Optic disc: Slightly blurred margins, mild hyperemia.

  • Retina:

    • Scattered perivascular sheathing in the peripheral retina ("candle-wax drippings" appearance).

    • No retinal hemorrhages or exudates.

  • Macula: Appears slightly thickened; OCT is pending.

  • Peripheral retina: No tears or detachments.

Left Eye (OS):

  • Normal fundus exam.

Would your residents like to:

  • Revise or expand their differential diagnosis now?

  • Suggest next steps in investigation (e.g., imaging, labs)?

Let me know how you'd like to proceed.

You said:

looks like the patient has a general desease

Ophthalmology Sim Patient Creator said:

Excellent observation — yes, the ocular findings, especially the bilateral granulomatous anterior uveitis with vitritis and perivascular sheathing, do suggest an underlying systemic condition rather than isolated ocular inflammation.

Given that, how would your residents like to proceed?

Please ask them to suggest the next steps in evaluation, for example:

  • Which laboratory investigations would they order?

  • Any imaging studies they would request?

  • Would they consider systemic referral (e.g., pulmonology, rheumatology)?

I’m ready to provide the results based on the steps they choose.

You said:

routine lab and torax CT scan

Ophthalmology Sim Patient Creator said:

Perfect — we'll proceed with:

  1. Routine lab investigations

  2. High-resolution CT (HRCT) of the thorax

🧪 Laboratory Results:

  • CBC: WNL

  • ESR: 45 mm/hr ↑

  • CRP: Mildly elevated

  • ACE (Angiotensin-Converting Enzyme): Elevated

  • Serum calcium: Mildly elevated (10.8 mg/dL)

  • Quantiferon-TB Gold: Negative

  • ANA: Negative

  • RPR / VDRL: Non-reactive

  • HIV: Negative

  • HLA-B27: Negative

🖼️ High-Resolution CT (Thorax):

  • Bilateral hilar and mediastinal lymphadenopathy

  • No pulmonary nodules, cavitations, or interstitial fibrosis

  • No pleural effusion

Would your residents now like to:

  • Update or narrow the differential diagnosis?

  • Consider biopsy or other systemic workup?

  • Discuss management options?

Let me know how you'd like to continue.

You said:

differential diagnosis

Ophthalmology Sim Patient Creator said:

Excellent — let's review the key clinical findings and then walk through a reasoned differential diagnosis based on what your residents have so far.

📋 Key Clinical Features:

  • 45-year-old African-American woman

  • Unilateral granulomatous anterior uveitis with vitritis and retinal periphlebitis

  • Elevated serum ACE and calcium

  • HRCT chest: Bilateral hilar and mediastinal lymphadenopathy

  • No infectious markers (TB, syphilis, HIV) or autoimmune markers (ANA, HLA-B27)

🧠 Differential Diagnosis for Granulomatous Uveitis with Systemic Findings:

1. Sarcoidosis

  • Most likely at this point:

    • Granulomatous uveitis

    • Vitritis and periphlebitis (candle-wax drippings)

    • Elevated ACE, serum calcium

    • Hilar lymphadenopathy

    • Demographic match

2. Tuberculosis (ocular TB)

  • Granulomatous uveitis is possible

  • Retinal vasculitis also possible

  • But Quantiferon-TB is negative

  • No pulmonary signs on HRCT

3. Syphilis

  • Can mimic almost any uveitis pattern

  • But serology (RPR/VDRL) is negative

4. Vogt-Koyanagi-Harada (VKH)

  • Granulomatous uveitis and vitritis possible

  • But no bilateral involvement or systemic prodrome (e.g., meningismus, hearing changes, vitiligo)

5. Lymphoma/Masquerade syndrome

  • Vitritis and subretinal infiltrates may occur

  • Usually in older age group; no lymphadenopathy pattern seen here

6. Idiopathic uveitis

  • Diagnosis of exclusion after ruling out systemic causes

Would your residents like to proceed to:

  • Biopsy (e.g., transbronchial lymph node biopsy) to confirm granulomatous inflammation?

  • Or begin discussing treatment planning based on presumptive diagnosis?

Let me know how you’d like to proceed.

You said:

biopsy

Ophthalmology Sim Patient Creator said:

Very good — a biopsy is the appropriate next step to confirm the suspected systemic diagnosis.

🧪 Transbronchial Lymph Node Biopsy Results:

  • Histology: Non-caseating granulomas composed of tightly clustered epithelioid histiocytes and multinucleated giant cells.

  • No necrosis or acid-fast bacilli seen

  • AFB stain: Negative

  • Fungal stains: Negative

✅ These findings are consistent with sarcoidosis and help confirm the systemic diagnosis in the context of the patient’s ocular and thoracic findings.

Would your residents now like to:

  • Begin discussing ocular and systemic treatment plans?

  • Consider any further tests (e.g., OCT or fluorescein angiography)?

  • Ask for confirmation of the diagnosis?

Let me know how you'd like to proceed.

You said:

systemic treatment, do we need further tests?

Ophthalmology Sim Patient Creator said:

Excellent — let's address both of your questions:

🩺 Systemic Treatment Planning for Sarcoid Uveitis

Management of sarcoid-associated uveitis focuses on controlling ocular inflammation and addressing systemic disease activity:

🔹 1. First-Line Systemic Therapy:

  • Oral corticosteroids (Prednisone):

    • Initial dose: ~0.5–1 mg/kg/day

    • Gradual taper over weeks depending on response

  • Consider periocular steroids (e.g., posterior sub-Tenon’s triamcinolone) if uveitis is localized and systemic side effects are a concern

🔹 2. Steroid-Sparing Agents (if prolonged therapy needed or corticosteroid side effects develop):

  • Methotrexate (most commonly used)

  • Alternatives: Azathioprine, mycophenolate mofetil

  • Start in collaboration with rheumatology or internal medicine

🔹 3. Biologic Agents (for refractory or severe cases):

  • Anti-TNF agents (e.g., infliximab, adalimumab) especially useful if there's posterior involvement or systemic sarcoid activity not controlled with DMARDs

🔬 Further Tests — Are They Needed?

At this point, you have:

  • Confirmed uveitis (granulomatous anterior and posterior)

  • Identified systemic sarcoidosis (clinical + radiological + biopsy)

  • Ruled out infectious and autoimmune mimickers

Additional helpful tests (optional, based on case severity):

1. Optical Coherence Tomography (OCT) – Macular Scan

  • Already suggested as pending

  • 📌 Useful for evaluating:

    • Macular edema

    • Epiretinal membrane

    • Subtle choroidal granulomas

2. Fluorescein Angiography (FA)

  • Especially if vasculitis is suspected or to monitor:

    • Retinal vascular leakage

    • Macular ischemia

    • Response to treatment

3. Chest and cardiac evaluation

  • Pulmonary function tests (PFTs)

  • ECG and/or cardiac MRI (if systemic sarcoidosis is extensive)

4. Neuroimaging

  • Only if there are neurological symptoms suggestive of neurosarcoidosis

Would you like me to summarize the final diagnosis and treatment plan for your residents, or are you planning to ask them for the final diagnosis first?

You said:

final

Ophthalmology Sim Patient Creator said:

Here is a summary to conclude the case:

✅ Final Diagnosis

Sarcoidosis-associated panuveitis (right eye), with confirmed systemic sarcoidosis.

🧠 Key Clinical Features That Led to Diagnosis:

  • Granulomatous anterior uveitis (mutton-fat KPs, AC cells/flare)

  • Vitritis and perivascular sheathing (“candle-wax drippings”)

  • Elevated ACE and serum calcium

  • Bilateral hilar lymphadenopathy on HRCT

  • Non-caseating granulomas on transbronchial lymph node biopsy

  • Negative infectious and autoimmune workup

💊 Systemic and Ocular Management Plan:

🔹 Initial:

  • Oral prednisone (e.g., 40–60 mg/day), with taper based on response

  • Consider periocular corticosteroids if localized posterior segment involvement

🔹 If steroid-sparing required:

  • Methotrexate (preferred first-line DMARD)

  • Consider rheumatology referral for systemic management

🔹 Biologics for refractory cases:

  • Adalimumab or Infliximab in collaboration with rheumatology

🔹 Adjunct investigations:

  • OCT: to assess macular edema

  • FA: if vasculitis or ischemia suspected

Would you like links to relevant images or references for teaching purposes?

You said:

yes please

Ophthalmology Sim Patient Creator said:

Certainly — here are some useful image resources and references to support your teaching on sarcoidosis-associated uveitis. These include examples of:

  • Granulomatous anterior uveitis

  • Vitritis and perivascular sheathing ("candle-wax drippings")

  • Chest CT findings in sarcoidosis

  • OCT findings like cystoid macular edema (CME)

  • Histopathology of non-caseating granulomas

Please remember:
🔹 Sometimes links may break. If so, go to the homepage and search for the image title in the content.
🔹 You may use these images and cases in yourpresentations for residents, as long as you provide appropriate source citations.

🖼️ 1. Ocular Findings in Sarcoid Uveitis

🔹 Mutton-fat Keratic Precipitates:

  • https://www.aao.org/image/mutton-fat-kps

🔹 "Candle-wax drippings" — Retinal periphlebitis:

  • https://eyewiki.org/File:Candlewaxdrippings.jpg
    (If the link does not open directly, visit: https://eyewiki.org and search “Candlewax drippings”)

🔹 Fundus image showing vitreous haze + vasculitis:

  • https://www.retinalphysician.com/issues/2016/july-august-2016/images-in-retina

🖼️ 2. OCT Findings — Cystoid Macular Edema (CME):

  • https://www.reviewofoptometry.com/CMSImagesContent/2018/01/0118_RO_Macula_Fig4.jpg
    (Classic CME from uveitis)

🖼️ 3. Chest Imaging: Hilar Lymphadenopathy in Sarcoidosis

  • https://radiopaedia.org/cases/sarcoidosis-1
    (Shows classic bilateral hilar lymphadenopathy)

🧪 4. Histopathology — Non-caseating granulomas

  • https://www.pathologyoutlines.com/topic/lungnonspecificgranuloma.html

  • https://basicmedicalkey.com/wp-content/uploads/2016/07/Fig.-14.28.jpg

📚 Additional Teaching Resources:

  • AAO Uveitis Section: https://www.aao.org/bcscsnippetdetail.aspx?id=f25f70e8-bd2f-45a4-aeac-824e19a254fa

  • EyeWiki Article on Sarcoid Uveitis: https://eyewiki.org/Sarcoid_Uveitis

  • Review Article – Sarcoidosis and the Eye: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340784/

Let me know if you'd like me to prepare a brief quiz or discussion points based on this case for your residents.