External lid examination was normal, while the anterior segment demonstrated nodular hyperemia and edema of the superior sclera (Figure 2), as well as posterior synechiae with scattered transillumination iris defects (Figure 3) and +3 nuclear sclerotic cataract.
No cellular reaction was detected in the anterior chamber. Superior vitreous debris was seen near the equator, while remaining posterior examination was normal.
The right eye was normal except with +1 nuclear sclerotic cataract.
Previous laboratory results showed positive Lyme disease serology, while negative qualitative syphilis (rapid plasma reagin), anti-nuclear antibody, toxoplasma, Rocky Mountain spotted fever, R. typhi IgM and IgG, B. henselae IgG and IgG, and B. quintana IgM and IgG titers. Outside testing also showed a normal angiotensin converting enzyme level of 27 units/L (Ref: 9 – 67), complete blood count, and chest radiography.