History of Present Illness (HPI)
A 67-year-old man presents 3 months after uncomplicated cataract extraction/intraocular lens implant (CE/IOL) right eye (OD) complaining of decreased vision and mild photophobia in the right eye. It has been progressive over the last 5 days. On postoperative day 1 after cataract surgery, he was 20/25− with 1+ white cells in the anterior chamber (AC) and trace corneal stromal edema, improving to 20/20 and a normal exam by week 1.
| OD | OS | |
|---|---|---|
| Vision | 20/60 | 20/20 |
| Intraocular pressure (IOP) | 25 | 15 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | See Fig. 5.1 | Clear |
| AC: | 2+ white cell | Deep and quiet |
| Iris: | Flat | Flat |
| Lens: | Posterior chamber intraocular lens (PCIOL) | PCIOL |
| Anterior vitreous: | 2+ anterior vitreous cells | Clear |
| Nerve: | Cup-to-disc (c/d) 0.4 | c/d 0.4 |
| Macula: | Flat, no edema | Unremarkable |
| Vessels: | Normal caliber and course | Normal caliber and course |
| Periphery: | Unremarkable | Unremarkable |
Further Questions to Ask
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Do you have any history of cold sores or genital ulcers?
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Have you ever had zoster on your face or head?
He answers no to all questions.
Assessment
Unilateral keratouveitis with ocular hypertension OD after cataract surgery
Differential Diagnosis
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Herpetic keratouveitis
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Retained lens fragment
Testing
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The patient needs gonioscopy (See Fig. 5.2 ) and a scleral depressed examination to rule out retained lens fragments.
