History of Present Illness (HPI)
A 39-year-old man with no significant past medical history complains of 2 days of tearing, light sensitivity, and blurry vision in his left eye (OS). It started first with some foreign body sensation and has progressed since then. His other eye is fine. He denies getting anything in the eye or being hit in the eye and denies contact lens use.
Exam
| OD | OS | |
|---|---|---|
| Vision | 20/20 | 20/40+ |
| IOP | 12 | 25 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | Trace injection |
| Cornea: | Clear | See Fig. 9.1 |
| AC: | Deep and quiet | 1+ white cell |
| Iris: | Flat | Flat |
| Lens: | Clear | Clear |
| Anterior vitreous: | Clear | Clear |
Dilated Fundus Examination (DFE)
| Nerve: | Normal, cup-to-disc (c/d) 0.3 | Normal, c/d 0.3 |
| Macula: | Good foveal reflex | Good foveal reflex |
| Vessels: | Normal caliber and course | Normal caliber and course |
| Periphery: | Unremarkable | Unremarkable |
Color slit lamp photograph of the left eye under normal illumination shows a particularly long dendriform lesion on the corneal epithelium nasal and superior to the visual axis. A few stellate keratic precipitates (KPs) were noted, which are less well visualized in this image.
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