History of Present Illness (HPI)
A 52-year-old woman with no past ocular history is referred to you for anterior uveitis in the left eye (OS). She presented to an outside ophthalmologist 1 week ago with decreased vision and photophobia. Outside records note 4+ white cells in the anterior chamber. She was started on difluprednate six times a day OS and cyclopentolate three times a day (TID) OS. Follow-up 5 days later noted still “3 to 4+ cells” OS. Difluprednate was increased to once every hour (q1h). She was seen the following day and still had not significantly improved, and was sent to you the following day.
The patient complains of profound vision loss and light sensitivity. She claims she had normal vision before this episode.
Past Medical History (PMH)
Coronary artery disease status post (s/p) stent
| OD | OS | |
|---|---|---|
| Vision | 20/20 | Count fingers (CF) 3′ |
| IOP | 20 | 8 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | 2+ injection |
| Cornea: | Clear | Clear |
| AC: | Deep and quiet | See Fig. 8.1 |
| Iris: | Flat | Poor view, flat |
| Lens: | Clear | Poor view |
| Nerve: | Cup-to-disc (c/d) 0.3, pink, sharp | No view |
| Macula: | Good foveal reflex | |
| Vessels: | Normal caliber and course | |
| Periphery: | Unremarkable |
Further Questions to Ask
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Have you had any trauma to this eye or the fellow eye?
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Have you ever had surgery on this eye or the other eye?
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Have you been sick recently? Any recent hospitalizations, fevers, chills, or infections?
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Do you use injection drugs?
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Have you had any other new symptoms in the rest of your body, like new rashes, joint pains, tick bites, oral or genital ulcers, or bloody stools?
She responds that she cannot recall ever having any trauma to either eye, and she has definitely never had surgery on either eye. She denied any recent infections or hospitalizations. She does note that she has had a rash on both lower extremities for over a month, which her cardiologist told her was “low-grade cellulitis.” She has a few aches and pains but nothing that she considers out of the ordinary and nothing that has changed of late. She denies injection drug use ( Figs. 8.1 and 8.2 ).
