A 30-year-old man has his fourth attack in two years of painful red eyes with blurred vision, this time with a visible white layer in the front of the right eye. He also suffers recurrent painful mouth ulcers and has had genital ulcers. Previous attacks were treated with drops alone and always returned.
Examination Findings
Visual acuity: 6/36 right, 6/24 left. Both eyes: anterior chamber cells with a mobile hypopyon in the right eye, vitritis, and retinal vasculitis with haemorrhages on dilated examination. Mouth: recurrent painful oral ulcers; history of genital ulcers. Pathergy-type skin lesions reported. He has had three similar eye attacks in two years.
Investigations
Slit-lamp and dilated fundus examination document the panuveitis, hypopyon and retinal vasculitis. The diagnosis rests on the clinical pattern — recurrent oral/genital ulcers with eye inflammation — supported by rheumatology assessment. Baseline workup before immunosuppression (blood counts, infection screening) follows local protocol. Fluorescein angiography, where available, maps the retinal vasculitis.
Questions to Think About
- What makes this more than ‘just’ anterior uveitis?
- Why did the previous drop-only treatments keep failing?
- What question in the history unlocks the diagnosis?
Diagnosis
Behçet disease with panuveitis: recurrent bilateral eye inflammation with hypopyon, plus recurrent oral and genital ulcers — a systemic vasculitis.
Reasoning
Reasoning: Recurrent bilateral panuveitis with mobile hypopyon and retinal vasculitis, plus recurrent oral and genital ulcers in a young man, is Behçet disease — a systemic vasculitis. The panuveitis (not anterior-only) and the mucocutaneous history exclude HLA-B27 disease; infection cannot explain the recurrent systemic pattern. Diagnosis: Behçet disease with panuveitis. Management: typical management includes systemic immunosuppression with rheumatology co-management per local protocol, not topical therapy alone, with retinal monitoring. He is told all his symptoms are one vessel disease needing body-wide treatment.
Differential Diagnosis
- HLA-B27 anterior uveitis — ruled out: the inflammation is panuveitis with retinal involvement and hypopyon, not isolated anterior uveitis, and the mucocutaneous ulcers point to Behçet.
- Infectious endophthalmitis — ruled out: the course is recurrent over years with oral/genital ulcers; infection does not explain the systemic pattern.
- Sarcoid uveitis — ruled out: no granulomatous KPs or iris nodules; the shifting hypopyon and mucosal ulcers fit Behçet.
Management
Typical management includes urgent rheumatology co-management with systemic immunosuppression per local protocol — topical treatment alone cannot control Behçet panuveitis — alongside ophthalmic monitoring of the retinal vasculitis. He is told his mouth ulcers, skin lesions and eye attacks are one disease of the blood vessels, that the eye inflammation needs body-wide treatment, and that early aggressive therapy protects vision.
Key Learning Points
- Behçet uveitis is a PANUVEITIS — front and back of the eye together — unlike the anterior-only attacks of HLA-B27 disease.
- The hypopyon in Behçet is famously MOBILE: it shifts when the patient tilts the head.
- Ask about mouth and genital ulcers in every young man with recurrent hypopyon uveitis — the diagnosis hides in the history.
- Retinal vasculitis is the sight-threatening component — the retina, not just the hypopyon, decides the prognosis.
- This is a systemic vasculitis: rheumatology co-management with immunosuppression is the standard, not drops alone.
Red Flags
- Hypopyon with retinal vasculitis in a young adult — think Behçet; examine the retina, not just the front.
- Recurrent oral/genital ulcers with eye inflammation — the systemic diagnosis is being missed.
- Retinal haemorrhages and vascular sheathing in uveitis — the sight-threatening lesion; escalate to immunosuppression.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.