History of Present Illness (HPI)
A 64-year-old woman with a history of moderate amblyopia right eye (OD) and herpetic keratitis with anterior uveitis left eye (OS) presents to your office complaining of decreased vision in the OS for the last few weeks. The last time she was seen was 6 months ago, when the uveitis and keratitis were both inactive. An episode of herpetic keratouveitis had left her with a paracentral corneal scar in the left eye and mildly decreased vision to about 20/40. Vision was correctable to 20/30 OS at her last visit with a hard contact lens, but she does not like to wear it. She notes that although the vision is decreased, she does not have the pain, tearing, redness, or light sensitivity that she has had with her previous flare-ups in that eye.
| OD | OS | |
|---|---|---|
| Vision | 20/125 | 20/60 |
| Intraocular pressure (IOP) | 14 | 13 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | See photo | Paracentral scar |
| Anterior chamber (AC): | Deep and quiet | Deep and quiet |
| Iris: | Transillumination defect (TIDs) superonasally | Flat |
| Lens: | Posterior chamber intraocular lens (PCIOL) | PCIOL |
| Anterior vitreous: | Clear | Clear |
| Nerve: | Cup-to-disc (c/d) 0.3, pink, sharp | c/d 0.3, pink, sharp |
| Macula: | Flat | Blunted foveal reflex |
| Vessels: | Normal caliber and course | Normal caliber and course |
| Periphery: | Unremarkable | Unremarkable |
Because of the decreased vision in the left eye and blunted foveal reflex on examination, optical coherence tomography (OCT) was ordered ( Fig. 72.1 ).
