History of Present Illness (HPI)
A 46-year-old woman with a history of anterior uveitis in the left eye (OS) associated with HLA-B27 presents to you from an outside ophthalmologist for a second opinion. She had her first episode of iritis 7 years ago. She responded well to drops and did not recur for almost a year. In the last 1 to 2 years, her flares have become more frequent and difficult to control. She is currently being treated for her third flare this year and has grown tired of the recurrences and frequent trips to the ophthalmologist’s office. She has had extensive testing for an underlying cause and only HLA-B27 was positive.
She is 3 weeks into this current flare. Her symptoms have subsided, and she has just started tapering her drops as per the usual routine.
Ocular medications:
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Prednisolone acetate 1% three times a day (TID) OS
| OD | OS | |
|---|---|---|
| Vision | 20/20 | 20/20 |
| IOP | 14 | 21 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | Clear | Clear |
| Anterior chamber (AC): | Deep and quiet | Trace cells, 1+ flare |
| Iris: | Flat | Flat |
| Lens: | Clear | Trace posterior subcapsular cataract (PSC), off center |
| Anterior vitreous: | Clear | 1+ cells |
| Nerve: | Cup-to-disc (c/d) 0.3, pink, sharp | c/d 0.3, pink, sharp |
| Macula: | Good foveal reflex | Good foveal reflex |
| Vessels: | Normal caliber and course | Normal caliber and course |
| Periphery: | Unremarkable | Unremarkable |
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