March 28, 2013 | POSTED BY | Articles, Clinical Optometry
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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.