History of Present Illness (HPI)
A 57-year-old man with a history of anterior uveitis both eyes (OU) associated with sarcoidosis presents for a scheduled sub-Tenon’s triamcinolone injection left eye (OS). The left eye was noted to be quiet 1 week ago at his last visit, but vision had declined due to recurrent cystoid macular edema (CME). He could not stay for an injection last visit so he returns today for the procedure.
Past Ocular History (POH)
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Anterior uveitis OU, as noted earlier, associated with sarcoidosis
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Uveitic glaucoma OU
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Phthisical right eye (OD) secondary to poorly controlled uveitis and uveitic glaucoma OD
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Medications:
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Mycophenolate mofetil 1000 mg by mouth (PO) twice a day (BID)
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Prednisolone acetate 1% daily OD
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Atropine 1% at bedtime daily OD
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Dorzolamide/timolol three times a day (TID) OS
Exam
OD
OS
Vision
Count fingers (CF) 3′
20/70
Intraocular pressure (IOP):
8
19
Lids and lashes:
Normal
Normal
Sclera/conjunctiva:
Trace injection
White and quiet
Cornea:
Band keratopathy
Clear
2+ stromal edema
Anterior chamber (AC):
Deep, no cells
Deep, no cells
2+ flare
1+ flare
Iris:
Flat
Flat
Lens:
Posterior chamber intraocular lens (PCIOL)
PCIOL
Dilated Fundus Examination (DFE)
Nerve:
No view
Cup-to-disc (c/d) 0.7, pink, sharp
Macula:
+CME
Vessels:
Normal caliber and course
Periphery:
Attached, no chorioretinal lesions
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Further Questions to Ask
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None. Patient is well known to you and has already consented to a sub-Tenon’s triamcinolone injection, which has worked well for his CME OS in the past ( Fig. 79.1 ).
