History of Present Illness (HPI)
A 58-year-old man with no significant past medical history presents for follow-up of anterior uveitis in the left eye (OS). He has been seen multiple times by outside ophthalmologists and has been on topical steroids for 2 months. He reports he has never been able to get off the steroids completely. He has had testing for an underlying cause of uveitis, all of which have been negative, including human immunodeficiency virus (HIV), syphilis, purified protein derivative (PPD), Lyme serologies, HLA-B27, angiotensin-converting enzyme (ACE), lysozyme, and a chest computed tomography (CT) scan to assess for pulmonary sarcoidosis. He notes some blurred vision OS, which has waxed and waned since the onset of the uveitis but has never been normal.
Ocular medications:
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Prednisolone acetate 1% three times a day (TID) OS
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Fig. 6.1
Color slit lamp photograph of the left eye shows sectoral atrophy of the inferior iris.
From Van der Lelij A, Ooijman FM, Kiljstra A, Rothova A. Anterior uveitis with sectoral iris atrophy in the absence of keratitis: A distinct clinical entity among herpetic eye diseases. Ophthalmology . 2000;107[6]:1164–1170.
| OD | OS | |
|---|---|---|
| Vision | 20/20 | 20/25− |
| IOP | 14 | 24 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | Trace injection |
| Cornea: | Clear | Clear, a few fine keratic precipitates (KP) |
| Anterior chamber (AC): | Deep and quiet | 1+ cells |
| Iris: | Flat | See Fig. 6.1 |
| Lens: | Clear | Clear |
| Anterior vitreous: | Clear | Clear |
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