A 44-year-old man noted mild photophobia, blurry near vision, bilateral cheek swelling (Figure 1), and enlargement of the left pupil for 4 days. He had a 3-month history of fever, malaise, night sweats, and a 7-kg weight loss.
Visual acuity was 20/25 OU at distance. Jaeger measure of near vision (with J1 about equal to 20/25) was J1 OD and J2 OS at 33 cm, and J1 OD and J7 OS at 20 cm with distance correction in place. Although the right pupil constricted briskly from 5 to 3 mm to light and accommodation, the left pupil measured 8 mm and constricted minimally and sluggishly. The anisocoria was more pronounced in the light than in the dark (Figure 2). The left pupil constricted following topical instillation of 1% but not ⅛% pilocarpine. Cranial nerve examination was otherwise unremarkable, including the remaining functions of the third nerve. Intraocular pressures were 14 mm Hg OD and 16 mm Hg OS. Fine keratic precipitates and mild anterior chamber reaction were present bilaterally. Funduscopic examination revealed 1+ anterior vitreous cells and creamy ovoid chorioretinal lesions in both eyes (Figure 3).
Blair MP, Rizen M. Heerfordt Syndrome With Internal Ophthalmoplegia. Arch Ophthalmol. 2005;123(7):1017. doi:10.1001/archopht.123.7.1017