Introduction
This month I am combining two cases of anterior uveitis as both of them pointed to an association to a systemic disease.
The first patient was seen by me. The second patient was seen at a community health center, where I followed a fourth year student.
Age/Sex/Race
42 year old Caucasian female
Chief Complaint
“My vision has been blurry for past two days. I went to see an Optometrist in Oklahoma since my eye was red and hurting. He gave me these two medications (1% Pred Forte and 2% Homatropine) and now my vision is blurry. I stopped taking both medications as my vision was burry.”
The patient was diagnosed with anterior uveitis two days prior, and was prescribed Pred Forte and Homatropine.
Medical History
None
NKDA
Ocular History
Presbyopia
Anterior Uveitis OD – 6 months ago
Medications
Homatropine
Pred Forte
Family History
None
Social History
Social drinker
Diagnosis and initial plan of action
Her vision is blurry because of Homatropine. I educated her that her vision is blurry because of Homatropine, and it’s very important for her to continue both the drops as prescribed by the doctor.
Applicable Testing & Results of Testing
Confrontation fields: FTFC OU
Extraocular muscles: Full OU
Pupils: PERRLA OS, Fixed and dilated pupil OD
Slit lamp examination
Lids/lashes – clear OU
Conjunctiva – mild circumlimbal injection OD, clear OS
Cornea –few keratic precipitates OD, clear OS
Anterior chamber – 2+ cell and flare OD, clear OS
Lens – Broken posterior synechiae and peripheral anterior synechiae OD, clear OS
This is what my patient’s eye looked like except the synechiae was broken.
IOP – 15 OU
Assessment and Plan
According to the patient, she wasn’t told that her eyes would be dilated. We told her to continue drops and come back in two days. Since she had mentioned about a previous uvieitis in the same eye, we were going to run some blood tests to rule out any underlying systemic diseases. We had to find her a primary care physician since she didn’t have one. We had told her that we will have some names for her when she returned in two days. We were going to order HLB-27, ANA, RF and CBC. When the patient returned after two days, her eye was much better. We also found out that she never finished her dosage completely for Pred Forte and Homatropine. Once her eye felt better, she stopped using both medications and didn’t go back to see her Optometrist. We believed that the second attack of anterior uveitis was due to the patient stopping her medication abruptly instead of tapering it off. This case showed how important it is to ask questions differently to make sure that the patient is telling you everything.
The second patient was seen at a community health center, where I followed a fourth-year student.
Age/Sex/Race
23-year-old African American female
Chief Complaint
“My right eye has been red for past three days. It started in the evening three days ago. It was watery and I had throbbing pain that came and went. My eye is much better now than in the morning.”
The patient was light sensitive at one point. Also, she said that she had a similar episode last year. No signs of itching, burning, flashes or floaters.
Medical History
Asthma
NKDA
Ocular History
Anterior Uveitis – 2 years ago
The patient said that she knows that she needs glasses for distance but hasn’t seen an Optometrist.
Medications
None
Family History
Mother – Gout, Rheumatoid Arthritis
Social History
Social drinker and smoker
Diagnosis and initial plan of action
Just from hearing her history, I thought that she probably had uveitis again.
Applicable Testing & Results of Testing
Confrontation fields: FTFC OU
Extraocular muscles: Full OU
Pupils: PERRLA, (-) APD OU
Slit lamp examinationL
Lids/lashes – clear OU
Conjunctiva – Circumlimbal injection OD, clear OS
Cornea – mild edema OD, clear OS
Anterior chamber – 4+ cell OD, clear OS
Lens – anterior synechiae OD, clear OS
This is what my patient’s eye looked like but it was attached at two places.
IOP – 10 OD, 17 OS
Assessment and Plan
From the findings, we diagnosed the patient with anterior uveitis. From the records, we found out that she had a similar episode two years ago in the same eye. We prescribed 1% Pred Forte 1 gtt Q1H OD and 2.0% Homatropine BID OD. We didn’t have any Homatropine or Atropine so we told the patient to get the prescription filled right away. She was told to come back in three days. Since her mother has gout and Rheumatoid Arthritis, we thought that she might have these same conditions which might be associated with this anterior uveitis. Her primary physician had run a blood test that week, and everything came out normal. She came back three days later, and the anterior uveitis had turned into full-blown vitritis (I didn’t get to see the patient this time as I wasn’t in the clinic). Now, the question is, is this a systemic association or just an idiopathic situation? You decide!
Conclusion
Both of the cases initially pointed toward a systemic association. The cases weren’t challenging but it showed how important it is to ask the right questions to get more information out of your patients. By asking the right questions, one can determine whether it is an idiopathic, unhealed uveitis or an association with systemic disease.
