Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Cytomegalovirus (CMV) Anterior Uveitis
History of Present Illness (HPI)
A 58-year-old man with no significant past medical history presents for follow-up of anterior uveitis in the left eye (OS). He has been seen multiple times by outside ophthalmologists and has been on topical steroids for 2 months. He reports he has never been able to get off the steroids completely. He has had testing for an underlying cause of uveitis, all of which have been negative, including human immunodeficiency virus (HIV), syphilis, purified protein derivative (PPD), Lyme serologies, HLA-B27, angiotensin-converting enzyme (ACE), lysozyme, and a chest computed tomography (CT) scan to assess for pulmonary sarcoidosis. He notes some blurred vision OS, which has waxed and waned since the onset of the uveitis but has never been normal.
Ocular medications:
Exam
| OD | OS | |
|---|---|---|
| Vision | 20/20 | 20/25− |
| IOP | 14 | 24 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | Trace injection |
| Cornea: | Clear | Clear, a few fine keratic precipitates (KP) |
| Anterior chamber (AC): | Deep and quiet | 1+ cells |
| Iris: | Flat | See Fig. 6.1 |
| Lens: | Clear | Clear |
| Anterior vitreous: | Clear | Clear |
Dilated Fundus Examination (DFE)
| Nerve: | Normal, cup-to-disc (c/d) 0.4 | Normal, c/d 0.5 |
| Macula: | Good foveal reflex | Good foveal reflex |
| Vessels: | Normal caliber and course | Normal caliber and course |
| Periphery: | Unremarkable | Unremarkable |
Further Questions to Ask
-
Have you ever had trauma to the eye? Have you ever had a hyphema/bleeding inside the eye?
-
Have you ever had shingles on your face or head?
He answers no to all questions.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here