History of Present Illness
A 38-year-old black Haitian male presented with worsening vision and floaters in his right eye (OD) for the past 2 weeks. The day before symptoms started, the patient felt a foreign body sensation while cutting lumber. He was evaluated by an outside physician, who started the patient on difluprednate drops without improvement.
| OD | OS | ||
|---|---|---|---|
| Visual acuity | 20/200+1 sc PH no improvement | 20/20 sc | |
| Intraocular pressure | 17 | 13 | |
| Pupils | 7 mm → 5 mm, +afferent pupillary defect (APD) | 7 mm → 4 mm | |
| External | Normal | Normal | |
| Lids/lashes | Normal | ||
| Conjunctiva/sclera | White and quiet, lids everted, and no foreign bodies | White and quiet | |
| Cornea | Granulomatous keratic precipitates (KP) | Clear | |
| Anterior chamber | 3+ cell with fibrin | Deep and quiet | |
| Iris | Posterior synechiae, no atrophy, no lesions | Round, reactive, no atrophy, no lesions | |
| Lens | Pigment on anterior lens surface | Clear | |
| Vitreous | 2+ vitreous haze | No vitreous cell or haze | |
| Dilated fundus examination (DFE) | Figs. 47.1A and B | Fig. 47.2 | |
Questions to Ask
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Any prior episodes of eye redness, floaters, or loss of vision?
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Any history of oral or genital ulcerations, joint pain, rashes, gastrointestinal distress, or sexually transmitted disease?
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Any history of illicit drug use, including intravenous drug use?
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Have there been any exposures to tuberculosis or at-risk individuals for tuberculosis?
The patient answers no to all of these questions.
Assessment
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Panuveitis with peripheral retinitis OD
