Ophthalmology
Question 44 of 97
A 29 year old man presents to the Emergency Department with a 6 hour history of a red and painful left eye with blurred vision. He has no significant past medical history but tells you he is awaiting rheumatology review for ongoing atraumatic back pain. Given the presentation what is the most likely cause for the back pain?
Answer:
The patient has features of acute anterior uveitis. This is associated with genetic subtype HLA-B27. Diseases associated with the HLA-B27 subtype can be remembered with the mnemonic PAIR, and include Psoriasis, Ankylosing spondylitis, Inflammatory bowel disease, and Reactive arthritis.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 |
