Research

JAMA Ophthalmology | Original Investigation

Distinguishing Uveitis Secondary to Sarcoidosis

From Idiopathic Disease
Cardiac Implications
Yong Seop Han, MD; Erick Rivera-Grana, MD; Sherveen Salek, MD; James T. Rosenbaum, MD

IMPORTANCE Idiopathic disease is the most frequent diagnosis in a uveitis clinic. The need to
distinguish sarcoidosis from idiopathic uveitis is controversial. However, cardiac involvement
in sarcoidosis can be life-threatening.

OBJECTIVE To report a series of patients with uveitis and cardiac sarcoidosis to illustrate the
importance of categorizing the causes of uveitis.

DESIGN, SETTING, AND PARTICIPANTS This retrospective observational case series reviewed
the medical records of 249 patients with uveitis who were referred to the Casey Eye Institute
between July 1, 2008, and February 28, 2017.

MAIN OUTCOMES AND MEASURES We describe patients who initially received a diagnosis of
idiopathic uveitis but subsequently received a diagnosis of sarcoidosis. Clinical data, including
ophthalmologic findings, were collected. We summarized the number of patients who initially
presented with idiopathic uveitis, the number of patients who recived a classification of
idiopathic uveitis after evaluation, the number of patients who underwent chest computed
tomography or an electrocardiogram, and the number of patients with ocular sarcoidosis.

RESULTS Of 33 patients with sarcoidosis, 21 (63.6%) were women and the mean (SD) age was
53.5 (13.8) years. Of 249 patients, the referring diagnosis was idiopathic uveitis for 179 (72%).
After history, examination, and laboratory testing, 127 (51%) were still considered to have
idiopathic disease. Fifty-three of the 179 patients (30%) with idiopathic disease underwent
chest computed tomography scanning. A diagnosis of presumed sarcoidosis, usually on the
basis of a chest computed tomography scan, was made in 19 patients (36.2%). As 14 patients
(5.6%) were previously known to have sarcoidosis, 33 patients (13.3%) were evaluated with
definite or presumed ocular sarcoidosis. We obtained electrocardiograms as a screen for
cardiac sarcoidosis on 14 (42.4%) of these patients. Nine patients with abnormal
electrocardiogram results were referred to cardiologists. Four of the 19 patients (21.1%) who
were referred for idiopathic uveitis but subsequently received a diagnosis of presumed
sarcoidosis were found to have episodes of ventricular tachycardia that required implantable
cardiac defibrillators. Distinguishing ocular sarcoidosis from idiopathic uveitis had potentially
life-saving implications for these patients. Author Affiliations: Casey Eye
Institute, Oregon Health & Science
University, Portland (Han, Rivera-
CONCLUSIONS AND RELEVANCE The present case series shows the potential utility of
Grana, Salek, Rosenbaum);
distinguishing sarcoidosis-associated uveitis from idiopathic uveitis. We suggest that patients Department of Ophthalmology,
older than 40 years with a history of idiopathic uveitis be evaluated with chest computed Institute of Health Sciences, College
tomography and an electrocardiogram if sarcoidosis is suggested on ophthalmic examination. of Medicine, Gyeongsang National
University, Jinju, Gyeongnam 52727,
South Korea (Han); Division of
Arthritis and Rheumatic Diseases,
Oregon Health & Science University,
Portland (Rosenbaum); Legacy
Devers Eye Institute, Portland,
Oregon (Rosenbaum).
Corresponding Author: James T.
Rosenbaum, MD, Casey Eye Institute,
Oregon Health & Science University,
3181 SW Sam Jackson Park Rd,
JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2017.5466 Mailcode L467AD, Portland, OR
Published online January 11, 2018. 97239 (rosenbaj@ohsu.edu).

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 Research Original Investigation
U
veitis is a major cause of visual loss and accounts for
10% of acquired blindness.1,2 Although understand-
ing the pathogenesis for uveitis is evolving, about 24%
to 55% of patients with uveitis have been commonly labeled
as having idiopathic uveitis or undifferentiated uveitis. The
prevalence of idiopathic uveitis is similar in studies from the
United States and from other countries.3-15 Therefore, idio-
pathic uveitis is the most common diagnosis in most US and
European clinics for uveitis.3 The frequency of the diagnosis
of idiopathic uveitis was recently confirmed in 3 prominent,
multicenter double-masked randomized clinical trials.16-18
Some examples of idiopathic uveitis may result from incom-
plete history taking or from incomplete laboratory testing.
Some patients who are categorized as having idiopathic uve-
itis may actually have sarcoidosis,19 tubulointerstitial nephri-
tis and uveitis,20 or ankylosing spondylitis.21,22
Sarcoidosis is a chronic, granulomatous multisystem dis-
ease of unclear cause that affects predominantly the lungs and
other organs, including the skin, nervous system, eyes, and
heart. 23, 2 4 The annual incidence of sarcoidosis varies
worldwide.24-26 The annual US age-adjusted incidence, in the
number of new cases per 100 000, was highest among Afri-
can American females (39.1 cases), followed by African Ameri-
can males (29.8 cases), white females (12.1 cases), and white
males (9.6 cases).27 While sarcoidosis usually occurs in indi-
viduals between the second and fifth decades of life, there is
a bimodal distribution and a second peak occurs in women
older than 50 years in Europe and Japan.24,28
Ocular sarcoidosis occurs in about 25% to 50% of
patients with systemic sarcoidosis.29-31 Ocular sarcoidosis
may manifest as anterior uveitis that mainly affects younger
patients or as panuveitis that is often seen in the middle and
older ages.30 As the disease progresses, ocular sarcoidosis
can involve all structures of the eye, such as the uvea, cor-
nea, sclera, optic nerve, orbit, and visual pathway. Many
argue that there is no need to go “hunting” for sarcoid
because making a diagnosis of ocular sarcoidosis does not
change the treatment compared with the treatment for idio-
pathic uveitis.
Cardiac involvement in sarcoidosis is rare, affecting
approximately 6% of all patients.29,32-34 Cardiac involve-
ment, however, can be life-threatening. We reported 4
patients with sarcoid-associated uveitis and ventricular
tachycardia presumably secondary to sarcoidosis. In each
case, establishing the cause of the uveitis led to a poten-
tially life-saving intervention.
Methods
This retrospective review was approved by the institutional
review board of Oregon Health & Science University and
included patients who were referred with a diagnosis of
uveitis to the Casey Eye Institute between July 1, 2008, and
February 28, 2017. Informed consent was not obtained
because this was a retrospective review of medical records.
All patients were referred with a diagnosis of uveitis.
The patients had undergone a variable amount of laboratory
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Sarcoid-Associated Uveitis and Cardiac Disease
Key Points
Question What are the implications in distinguishing uveitis
secondary to sarcoidosis from idiopathic disease?
Findings In this case series that included 249 consecutive
patients with uveitis, the referring diagnosis was idiopathic for 179
(71.9%). Nineteen patients referred for idiopathic uveitis
subsequently received a diagnosis of presumed sarcoidosis,
usually on the basis of findings on chest computed tomography,
and 4 of these 19 were found to have episodes of ventricular
tachycardia requiring implantable cardiac defibrillators.
Meaning The present case series shows the potential utility of
distinguishing sarcoidosis-associated uveitis from idiopathic
uveitis.
investigation before being referred. All patients who were
referred to the uveitis clinic underwent an ophthalmic
examination and provided a detailed medical history. In
obtaining the history, we searched for clues, such as bowel
symptoms or chronic low back pain, that might point to a
specific cause. For all patients who remain in the idiopathic
category after history and examination, we obtained a sero-
logic test for syphilis and chest radiography results. Assum-
ing that both these tests yielded negative or normal results,
we recommended a chest computed tomography (CT) for
patients 40 years or older. We were hesitant to recommend
a chest CT for younger patients because of the amount of
radiation. We accepted symmetric hilar or mediastinal
adenopathy as diagnostic of presumed sarcoidosis in
patients who also had uveitis based on the First Interna-
tional Workshop of Ocular Sarcoidosis Guidelines.30
A diagnosis of presumed ocular sarcoidosis on the basis
of a chest CT examination showing symmetric hilar
adenopathy and the presence of uveitis was first described
by Winterbauer et al.35 In the report by Kaiser et al19 on the
use of chest CT in evaluating patients with sarcoidosis, all 14
patients with uveitis and symmetric adenopathy who
underwent mediastinal biopsy had noncaseating granulo-
mas that were detected histologically.
SPSS, version 20.0 (IBM) was used for data analysis. The
association between multiple peripheral chorioretinal atro-
phic lesions (MPCALs) and severe cardiac sarcoidosis neces-
sitating implantable cardiac defibrillator (ICD) was analyzed
using odds ratios. A P value of less than .05 was considered
statistically significant.
Results
Over 8 years and 8 months of medical record review, 249
patients were referred for a diagnosis of uveitis. One hun-
dred seventy-nine of these patients (72%) were considered
to have idiopathic uveitis at the time of referral. Fifty-three
(30%) underwent chest CT scans, and 17 patients (34%) had
scans that were found to have adenopathy consistent with
sarcoidosis. One additional patient who previously received
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 Sarcoid-Associated Uveitis and Cardiac Disease
Table 1. Demographics of Patients With Sarcoidosis and Patients Undergoing CT Scan
Patients With Sarcoidosis
Patients Undergoing Initially Presenting
CT Scan, With Idiopathic Uveitis,
No. (%) No. (%)
Characteristic (n=53) (n=19)
Age, mean 51.1 (15.1;10-82) 55.4 (13.3;35-82)
(SD; range), y
Female 41 (77) 16 (84)
Race/ethnicity
White 46 (87) 18 (95)
Asian 2 (4) NA
African American 2 (4) 1 (5)
Hispanic 1 (2) NA
White/black 1 (2) NA
White/Native 1 (2) NA
American
a diagnosis of idiopathic uveitis was presumed to have ocu-
lar sarcoidosis on the basis of hilar adenopathy that was
identified by chest radiography. Another patient was pre-
sumed to have sarcoidosis, as this was the best unifying
diagnosis for the combination of uveitis, orbital mass, and
optic neuropathy. Most patients were women, and the
demographics of these patients are presented in Table 1.
Patients who did not have a CT scan were younger than age
40 years or had a phenotype of uveitis, such as sudden
onset, unilateral, or anterior, that was not likely to be asso-
ciated with sarcoidosis. In addition, CT scans were recom-
mended for some patients who declined because of con-
cerns about cost, radiation, or inconvenience. Because 14 of
the original 249 patients had a prior diagnosis of sarcoid-
osis, the series consisted of 33 patients with presumed ocu-
lar sarcoidosis. After evaluation in the uveitis clinic, the
number of patients with idiopathic uveitis went from 179 to
127.
Of the 33 patients with definite or presumed ocular sar-
coidosis, 14 (42.4%) underwent electrocardiograms (EKGs).
The clinic began to order EKGs routinely for patients with
ocular sarcoidosis only in the last 3 to 4 years. Furthermore,
many patients with known sarcoidosis before referral had
recently received EKG results. Nine EKGs yielded abnormal
results such that patients were referred to a cardiologist.
Cardiac sarcoidosis with ventricular tachycardia was diag-
nosed in 4 (44.4%), each of whom had a chest CT scan that
showed a symmetric hilar adenopathy and each of whom
had initially received a diagnosis of idiopathic disease. Thus
4 of 33 patients (12%) with ocular sarcoidosis and 4 of 19
patients (21%) with presumed ocular sarcoidosis and an ini-
tial diagnosis of idiopathic uveitis had cardiac sarcoidosis.
The age of these 4 patients at presentation in the uveitis
clinic ranged from 66 to 67 years (mean [SD] 66.8 [0.3]
years), all 4 patients were women, and they were all white.
Table 2 summarizes clinical information on the participants
in this report. Multiple peripheral chorioretinal atrophic
lesions were observed in 3 of the 4 patients (75%).
The time between the onset of ocular symptoms and the
first visit to the Casey Eye Institute with a presumptive
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Original Investigation Research
Patients With a Prior
Diagnosis of Total Patients
Sarcoidosis, With Sarcoidosis,
No. (%) No. (%)
(n=14) (n=33)
52.1 (15.6;23-75) 53.5 (13.8;23-82)
5 (36) 21 (64)
10 (71) 28 (85)
3 (21) 3 (9)
1 (7) 2 (6)
NA NA
NA NA
NA NA Abbreviations: CT, computed
tomography; NA, not applicable.
diagnosis of idiopathic uveitis varied, ranging from 9 weeks
to more than 10 years. Three patients received a diagnosis of
sarcoidosis-associated uveitis within 4 weeks of referral,
whereas it took 128 weeks for 1 patient to receive a diagno-
sis. The median time from the diagnosis of sarcoidosis-
associated uveitis to the diagnosis of cardiac sarcoidosis was
50 weeks (interquartile range, 12-118 weeks). Three patients
received a diagnosis of cardiac involvement within 48
weeks to 140 weeks. One patient received a simultaneous
diagnosis of ocular sarcoidosis and cardiac sarcoidosis
(Table 2). The length of time to diagnose sarcoidosis and
cardiac sarcoidosis was affected by changes in the diagnos-
tic algorithm used to evaluate patients with uveitis. These
changes were a result of publications19,26,30,35-38 and the
evolving clinical experience.
All 4 patients had negative findings on angiotensin-
converting enzyme tests and chest radiography, but a chest
CT revealed sarcoidosis. Magnetic resonance imaging (MRI),
positron emission tomography (PET), and abdominal CT
results revealed that all 4 patients had pulmonary involve-
ment. Two of 4 patients (50%) had no cardiovascular symp-
toms before undergoing screening with an EKG or Holter
monitor. All patients showed ventricular tachycardia. Two
patients experienced premature ventricular contractions.
After undergoing medical treatments following the manifes-
tations of cardiac sarcoidosis, all 4 patients underwent ICD
implantation. All 4 patients showed stable cardiac function
and no active ocular inflammation at the last follow-up after
treatment of ocular sarcoidosis and cardiac involvement.
Treatment information is provided in Table 2. All patients
were treated with oral corticosteroids and a steroid-sparing
immunomodulatory drug, either azathioprine (1.5-2.5
mg/kg/day) or methotrexate (15-25 mg/week either orally or
sucutaneously) with daily folic acid supplementation.
Of the 4 patients with sarcoid uveitis combined with
cardiac sarcoidosis, there were 3 patients (75%) with
MPCAL. Of the 29 patients with sarcoidosis-associated uve-
itis without cardiac sarcoidosis, 12 patients (41.4%) had
MPCAL. Multiple peripheral chorioretinal atrophic lesions
were not significantly or more frequently observed in
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 Research Original Investigation Sarcoid-Associated Uveitis and Cardiac Disease

Table 2. Characteristics of Patients With Cardiac Sarcoidosis and Sarcoidosis-Associated Uveitis

Who Present Initially With Idiopathic Uveitis

Characteristic Patient 1 Patient 2 Patient 3 Patient 4

Ocular surgical history Cataract, bilateral None None Cataract,
both/RRD right eye
Initial symptoms/signs Blurred vision, Floater, fogginess, Floater Decreasing vision
decreased VF, and photophobia and photophobia and photophobia
and enlarged blind
spot
BCVA (right, left) 20/20, 20/20 20/25, 20/25 20/30, 20/25 20/400, 20/60
at the first visit
Type of uveitis at first Intermediate Anterior bilateral Anterior bilateral Anterior bilateral
visit, laterality bilateral (3+, 2+) (trace, trace) and (trace, trace) and
(right, left anterior (trace, trace) panuveitis bilateral intermediate bilateral
chamber cells)
Ocular lesion, laterality Optic disc swelling Mutton-fat KP MPCAL bilateral, Peripapillary chorioretinal
in the right eye bilateral, and vitreous atrophic lesions bilateral
iris synechiae snowball bilateral and
bilateral, ERM in the left eye
MPCAL bilateral,
and mild retinal
vasculitis bilateral
Increased ACE/chest −/−/+ −/−/+ −/−/+ −/−/+
radiography
evidence/chest CT
evidence
Treatments before Prednisone Prednisone Prednisone Prednisone
definitive diagnosis of and and and azathioprine
CS azathioprine MTX
Presenting symptoms No Yes No Yes
of CS (palpitation, chest
pain, edema, syncope,
or no symptom)
Manifestation of CS VT PVCs PVCs, Complete AV block
followed by definitive and VT VT, and
diagnosis by cardiac and cardiomyopathy VT
MRI and PET
Surgical management ICD ICD Cardiac ablation Pacemaker
for CS ICD ICD
Abbreviations: ACE, angiotensin
Other systemic Pulmonary, Pulmonary Pulmonary Pulmonary,
manifestations of glandular, neurosarcoidosis converting enzyme; AV,
sarcoidosis splenic involvement atrioventricular; BCVA,
Time between 9 wk 12-14 wk 21 mo More than 10 y best-corrected visual acuity; CEI,
the onset of ocular Casey Eye Institute; CS, cardiac
symptoms to the first sarcoidosis; CT, computed
visit with idiopathic tomography; ERM, epiretinal
uveitis at CEI membrance; ICD, implantable
Time between 2 wk 10 days 4 wk 128 wk cardioverter defibrillator; KP, keratic
the first visit with precipitate; MPCAL, multifocal
idiopathic uveitis at CEI
peripheral chorioretinal atrophic
to the diagnosis of OS
lesions; MRI, magnetic resonance
Time between 48 wk 52 wk 140 wk 0 wk
imaging; MTX, methotrexate; OS,
the diagnosis of OS to
the diagnosis of CS ocular sarcoidosis; PET, positron
emmision tomography; PVCs,
Outcome BCVA (right, left); BCVA (right, left); BCVA (right, left); BCVA (right, left);
at the last follow-up 20/20, 20/20; 20/20, 20/20; 20/20, 20/25; 20/400, 20/80; premature ventricular contractions;
no active ocular no active ocular no active ocular no active ocular RRD, rhegmatogenous retinal
inflammation; inflammation; inflammation; inflammation; detachment; VF, visual field; VT,
azathioprine prednisone; MTX, folic acid azathioprine; ventricular tachycardia; +, positive;
MTX, folic acid prednisone −, negative.

patients with severe cardiac sarcoidosis necessitating ICD
implantation compared with those without (odds ratio,
4.25; 95% CI, 0.39-45.96; P = .31).
Discussion
To our knowledge, idiopathic uveitis remains the most com-
mon diagnosis in most tertiary referral clinics. The term idio-
pathic is unsatisfying to both physicians and patients. How-
ever, the treatment for most forms of noninfectious uveitis is
nonspecific. Therefore, skeptics argue that categorizing uve-
itis into a specific cause has no therapeutic implication. In this
article, we described 4 patients who were referred with a di-
agnosis of idiopathic uveitis. With limited testing, we were able
to establish a diagnosis of sarcoidosis as the likely cause. Fur-
ther, the diagnosis of sarcoidosis had implications that were
potentially life-saving. Although Portland, Oregon, has a small
African American population for a city its size, this article vali-
dates the use of chest CT scanning in selected patients with
uveitis, as noted in a previous study from Cleveland, Ohio,19
a city with a larger African American population.
Cardiac manifestations are not clinically apparent in most
patients with sarcoidosis, and sudden cardiac death or tachyar-

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 Sarcoid-Associated Uveitis and Cardiac Disease
rhythmia may be the initial manifestation of cardiac sarcoid-
osis (CS).39,40 The prevalence of clinically silent CS is reported
in 3.7% to 54.9% of patients with CS.41 A few studies have re-
ported that some patients with clinically silent CS have cardiac
events, although there is considerable controversy regarding the
prognosis of patients with clinically silent CS.41 Therefore, car-
diac monitoring on asymptomatic patients with sarcoidosis may
be required. In this study, 2 of 4 patients (50%) were asymp-
tomatic before the diagnosis of cardiac sarcoidosis. Only 1 pa-
tient had definitive cardiovascular symptoms. Clinically evi-
dent cardiac involvement was reported in 2.4% to 6.5% of
patients with systemic sarcoidosis.29,32-34 In autopsy studies,
cardiac involvement was reported in 20% to 30% of patients
with sarcoidosis.39,42 In Japan, cardiac sarcoidosis is report-
edly responsible for up to 85% of sarcoidosis-related deaths.31,43
Our findings validate a report from Japan on cardiac sar-
coidosis and uveitis. Umazume and colleagues29 reported that
severe cardiac involvement that led to implantation of a pace-
maker was found in 7 patients (6.5%) with ocular sarcoidosis
between 1997 and 2009. For a definite diagnosis of cardiac sar-
coid, the presence of noncaseating granulomas on myocar-
dial tissue with no alternative cause is recommended.38,44 How-
ever, a myocardial biopsy is not often performed, and only
approximately 25% of patients with cardiac sarcoidosis have
a noncaseating granuloma identified on an endomyocardial
biopsy.45 Therefore, the diagnosis of most cases of cardiac sar-
coidosis has been “probable” using World Association for Sar-
coidosis and Other Granulomatous Disorders criteria, which
consist of (1) treatment-responsive cardiomyopathy or atrio-
ventricular node block, (2) reduced left ventricular ejection
fraction in the absence of other clinical risk factors, (3) unex-
plained sustained (spontaneous or induced) ventricular tachy-
cardia, (4) Mobitz type 2 or third-degree heart block, (4) de-
layed enhancement or T2 prolongation on a cardiac MRI, (5)
patch uptake on a dedicated cardiac PET, (6) positive gallium
uptake study, and (7) a defect on perfusion scintigraphy or
single-photon emission CT.38,44 Imaging modalities, such as
cardiac MRI and PET, may reveal early granulomatous dis-
ease and have been increasingly used for diagnosing preclini-
cal cardiac involvement. All patients in this case series did not
undergo a myocardial biopsy, but chest CT, cardiac MRI, and
PET results revealed the evidence of sarcoidosis.
If there is a mechanism with which to predict cardiac sar-
coidosis, it will be quite worthwhile. Umazume and
colleagues29 investigated whether ocular findings of sarcoid-
osis can predict severe cardiac involvement resulting in pace-
maker implantation. They concluded that MPCALs were ob-
served significantly and more frequently in patients (6 of 7
patients) with concurrent ocular sarcoidosis and severe car-
diac sarcoidosis, suggesting that severe cardiac involvements
may be predicted by specific fundus lesions.29 The reason why
MPCALs are significantly observed in patients with severe car-
diac sarcoidosis and whether MPCALs would appear before car-
diac involvement remain unclear. As Umazume and
colleagues29 have noted, microcirculatory disturbances may
be involved in forming fundus atrophic lesions and myocar-
dial scars. In this case series, 3 of 4 patients (75%) necessitat-
ing ICD implantation showed MPCAL on fundus examination
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Original Investigation Research
results. However, on statistical analysis MPCALs were not sig-
nificantly more frequently observed in patients with severe car-
diac sarcoidosis who needed ICD implantation compared with
those without. This result fails to confirm this conclusion by
Umazume and colleagues.29 Considering that few patients un-
derwent ICD implantation in this case series, further research
may be required. Patients with ocular sarcoidosis may have not
only MPCALs but also extensive chorioretinal atrophy in the
posterior pole secondary to longstanding involvement from
ocular sarcoidosis.46 In this case series, patient 4 showed peri-
papillary chorioretinal atrophy, but this was not extensive.
Immunomodulatory therapy, such as prednisone and
methotrexate, was recommended for cardiac sarcoidosis
based on the presence of ventricular arrhythmias, hyper-
metabolic activity on a cardiac PET scan, and/or left ven-
tricular dysfunction. 47 The combination of medications
could reduce toxicity and enhance steroid sparing. The
combination of prednisone and methotrexate compared
with prednisone alone has been reported as less toxic and
more effective. 48 Two patients (patient 1 and patient 4)
received combination treatment with prednisone and aza-
thioprine, and the other 2 patients were treated with pred-
nisone and methotrexate following a diagnosis of cardiac
sarcoidosis.
An ICD has been considered as the main therapy for pa-
tients with cardiac sarcoidosis with sustained ventricular tachy-
cardia, prior cardiac arrest, or a left ventricular ejection frac-
tion of 35% or less, despite optimal medical therapy and a
period of immunosuppression.38 The implantation of a pace-
maker has been considered as the necessary therapy for pa-
tients with an advanced atrioventricular block. 38 In the
present case series, all 4 patients underwent ICD implanta-
tion because of ventricular tachycardia, and 1 patient (patient
4) underwent a pacemaker implantation because of a com-
plete atrioventricular block. All patients showed stable car-
diac function without cardiovascular complications at the last
follow-up.
Limitations
The major limitation of this study is that the conclusion is
based on only 4 patients. However, the conclusion is vali-
dated by comparable observations published previously by
Umazume and colleagues.29
Conclusions
tj;3This case series demonstrates the need to recognize car-
diac sarcoidosis in elderly patients with sarcoidosis-
associated uveitis who present initially with idiopathic uve-
itis. Our current practice is to obtain a CT scan for all patients
with idiopathic uveitis, an age older than 40 years, and a phe-
notype of disease that is suggestive of sarcoidosis. Generally,
this means bilateral disease with intermediate or posterior in-
volvement. We would also recommend CT scans for a disease
that affects only the anterior segment if it had granuloma-
tous features. If the CT scan reveals a bilateral hilar adenopa-
thy, we obtain an EKG. We also question the patient regarding
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 Research Original Investigation
possible symptoms to suggest arrhythmia or heart failure. If
the EKG results show any conduction delay or rhythm distur-
bance, or if the review of systems suggests cardiac disease, we
refer the patient to a cardiologist for additional cardiac imaging
ARTICLE INFORMATION
Accepted for Publication: October 17, 2017.
Published Online: January 11, 2018.
doi:10.1001/jamaophthalmol.2017.5466
Author Contributions: Dr Rosenbaum had full
access to all the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Salek, Rosenbaum.
Acquisition, analysis, or interpretation of data:
All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: All authors.
Obtained funding: Rosenbaum.
Administrative, technical, or material support: Salek.
Supervision: Salek, Rosenbaum.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest. Dr
Rosenbaum reports receiving consulting fees from
Gilead, Abbvie, UCB, Regeneron, and Eyevensys;
research support from Alcon Research Institute;
speaking fees from Mallincrokdt; and royalties from
UpToDate. He owns stock in Novartis. No other
disclosures are reported.
Funding/ Support: This work was supported by
National Institutes of Health grants EY020249 and
EY06572, the William and Mary Bauman
Foundation, the Stan and Madelle Rosenfeld Family
Trust, and Research to Prevent Blindness.
Role of the Funder/Sponsor: The funding sources
played no role in the design and conduct of the
study; collection, management, analysis, or
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
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