History of Present Illness (HPI)
A 42-year-old man with no significant past ocular or medical history complains of progressively decreased vision in his right eye (OD) over the last 1 to 2 months. He says he can only see a small sliver of the world out of the bottom portion of the right eye. He denies problems in the left eye (OS).
| OD | OS | |
|---|---|---|
| Vision | Count fingers (CF) 3′ | 20/20 |
| Intraocular pressure (IOP) | 8 | 15 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | Clear | Clear |
| Anterior chamber (AC) | 3+ cell 2+ flare | Deep and quiet |
| Iris | Nearly 360-degree synechiae | Flat |
| Small pupil | ||
| Lens | Clear | Clear |
| Anterior vitreous | +Haze, unclear grade | Clear |
| Dilated fundus examination (DFE): | No view | Normal |
B scan ultrasound is pursued because there is no view of the fundus ( Fig. 45.1 ).
Questions to Ask
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Do you have any history of eye problems?
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Have you ever had surgery on either eye or trauma to either eye?
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Have you traveled outside the country recently?
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Do you practice safe sex?
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Have you started any new medications recently or been ill in the last few months?
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Do you have any joint pain, back pain, new skin rashes, problems with bowel movements, or oral or genital ulcers?
The patient denies any history of eye problems, eye surgery, or trauma. He reaffirms that he is healthy and has not been on any new medications. He has had low-back pain for 2 years but works in a warehouse and has always attributed it to his labor.
Assessment
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Panuveitis OD
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Retinal detachment OD, likely exudative
Differential Diagnosis
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Sarcoidosis
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Idiopathic
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HLA-B27–associated uveitis
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Syphilis
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Less likely: other infectious causes of panuveitis with serous detachment, such as tuberculosis and toxoplasmosis, or primary or secondary intraocular lymphoma
Working Diagnosis
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Noninfectious panuveitis, but with need to rule out infectious etiologies before using intensive corticosteroid therapy
Testing
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B scan as noted earlier
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Check HLA-B27, angiotensin-converting enzyme (ACE), lysozyme, chest x-ray, fluorescent treponemal antibody absorption (FTA-ABS), rapid plasma reagin (RPR), purified protein derivative (PPD) or QuantiFERON, and toxoplasma serologies
Management
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Start prednisolone acetate 1% every 2 hours (q2h) OD and cyclopentolate 1% three times a day (TID) OD
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Await results of testing
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Follow up in 1 week
Follow-up
HPI
The patient returns a week later. He says his vision is maybe slightly better, but he does not really notice a consistent change. All testing is negative aside from positive HLA-B27.
