Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

First Episode of Acute Iritis


History of Present Illness (HPI)

A 32-year-old man with no past ocular or medical history complains of 3 days of light sensitivity and redness in his left eye. He woke up with the symptoms and thought that maybe he had gotten something into his eye while sleeping. The symptoms have not improved and, he reports, have probably gotten worse.

Exam
OD OS
Vision 20/20 20/25−
IOP 14 9
Lids and lashes: Normal Normal
Sclera/conjunctiva: White and quiet See Fig. 4.1
Cornea: Clear Clear
Anterior chamber (AC): Deep and quiet 3+ cells, 2+ flare
Iris: Flat Flat
Lens: Clear 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: Good foveal reflex Good foveal reflex
Vessels: Normal caliber and course Normal caliber and course
Periphery: Unremarkable Unremarkable

Fig. 4.1, Color external photograph of the left eye shows severe ciliary flush.

Further Questions to Ask

  • Have you had any trauma to the left eye (OS) or the fellow eye?

  • Any recent illnesses or hospitalizations?

  • Have you used any new medications recently?

  • Have you gone camping or had any tick bites recently?

  • Perform a review of systems with particular focus on joints, skin, lungs, and the gastrointestinal tract.

The patient answers no to all questions.

Assessment

  • Acute anterior uveitis, OS

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