Ophthalmology
Question 139 of 180
A 27 year old woman presents to the Emergency Department with a 12 hour history of a painful, red left eye. She describes the pain increasing when reading and in bright lights. She has a past medical history of depression and ulcerative colitis. On examination you note a perilimbal flush. What is the likely diagnosis?
Answer:
The patient has features of acute anterior uveitis. Patients with the HLA-B27 genetic marker are at increased risk of acute anterior uveitis. Ulcerative colitis is a condition associated with HLA-B27.Anterior Uveitis (Iritis)
Ophthalmology
Last Updated: 9th June 2021
Anterior uveitis involves inflammation of the iris and ciliary body.
Causes
- Systemic autoimmune disorders
- Seronegative spondyloarthropathies, Behcet's disease, sarcoidosis, psoriasis, multiple sclerosis
- Infection
- Common infectious causes are herpes simplex, varicella zoster virus, cytomegalovirus and toxoplasmosis
- Trauma
- Neoplasia
- Risk factors
- Personal history of anterior uveitis
- Having the genetic marker HLA-B27
Clinical features
- Symptoms
- Painful red eye (pain may be worse when the person is contracting the ciliary muscle e.g. reading)
- Diminished or blurred vision
- Watering of the eye
- Photophobia
- Signs
- Ciliary flush (conjunctival injection exacerbated at the corneal limbus)
- Small fixed irregular pupil (due to adhesions)
- Eye tender to palpation through eyelid
- Positive Talbot's test (pain increases as the eyes converge and pupils constrict)
- Slit lamp examination:
- Synechiae
- Iris adherence to either the cornea (anterior synechia) or lens (posterior synechia)
- Flare
- Inflammation and leucocytes floating in aqueous humour of anterior chamber, hypopyon may be seen
- Keratic precipitates
- Lymphocyte aggregates on corneal endothelium
- Synechiae
Management
- Urgent ophthalmology referral is required to confirm the diagnosis with slit lamp examination with dilated pupils and measurement of intraocular pressure.
- Corticosteroids are used to reduce inflammation and prevent adhesions in the eye. They may be given topically, orally, intravenously, intramuscularly, or by periocular or intraocular injection or implant.
- A cycloplegic-mydriatic drug (for example cyclopentolate 1% or atropine 1%) may also be given to paralyse the ciliary body. This relieves pain and prevents adhesions between the iris and lens.
- People with severe or chronic uveitis may also be given systemic immunosuppressive drugs, tumour necrosis factor (TNF) inhibitors, laser phototherapy, cryotherapy, or have the vitreous removed surgically (vitrectomy).
- Infectious uveitis (bacterial, viral, fungal, or parasitic) is treated with an appropriate antimicrobial drug as well as corticosteroids and cycloplegics.
Complications
- Permanent vision loss
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
