History of Present Illness (HPI)
A 40-year-old woman with a history of chronic idiopathic anterior uveitis in the right eye (OD) complains of progressively decreasing vision in this eye for the last 6 months. She was diagnosed with uveitis almost a decade ago and has required many rounds of intensive topical steroid therapy and even a few courses of oral prednisone. She has been stable on methotrexate 15 mg by mouth (PO) every week for the last year.
Exam
| OD | OS | |
|---|---|---|
| Vision | 20/100 | 20/20 |
| Intraocular pressure (IOP) | 16 | 17 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | Clear | Clear |
| Anterior chamber (AC): | Quiet, 1+ flare | Deep and quiet |
| Iris: | Flat | Flat |
| Lens: | See Fig. 75.1 | Clear |
| Anterior vitreous: | Clear | Clear |
Dilated fundus examination (DFE)
| Nerve: | Cup-to-disc (c/d) 0.3, pink, sharp | c/d 0.3, pink, sharp |
| Macula: | Flat | Flat (poor view) |
| Vessels: | Normal caliber and course | Normal caliber and course |
| Periphery: | Attached | Attached |
