History of Present Illness (HPI)
A 35-year-old healthy woman with no significant past medical or ocular history is referred to the uveitis clinic by an outside ophthalmologist for “bilateral acute anterior uveitis.” She reports that her symptoms started a little over a month ago. Her eyes started to become red and very light sensitive. The referral note mentions that she was started on prednisolone acetate 1% four times a day (QID) both eyes (OU) for “4+ cells” in both anterior chambers and timolol 0.5% twice a day (BID) OU for an intraocular pressure (IOP) of 32 OU upon presentation. Since then, the photophobia and redness have decreased somewhat, she says, but not completely. The referral note goes on to add that despite some symptomatic relief, the cellularity has remained unchanged.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/25 pinhole (PH) 20/20 | 20/40 PH 20/20 |
| IOP | 28 | 27 |
| Sclera/conjunctiva | Trace injection | Trace injection |
| Cornea | Clear stroma, pigment on inferior endothelium | Clear, pigment on inferior endothelium |
| Anterior chamber (AC) | 4+ pigmented cells, 2+ flare | 4+ pigmented cells, 2+ flare |
| Iris | See Figs. 14.1 and 14.2 | See Figs. 14.1 and 14.2 |
| Lens | Clear | Clear |
| Anterior vitreous | 1+ pigmented cells | 1+ pigmented cells |
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