Intern Case Presentation Eye Probs Heidi Rogers PGY-1 5/29/15

CC: Eye problem HPI: 32 yo male who presents to the ED for 5 day history left eye pain and redness.

Red Eye: Important Questions to Ask Blurred or decreased vision Pain Photophobia Hx of trauma Itch: allergic conjunctivitis Previous episode Iritis, dendritic ulcer Contact Lens wearer: corneal infections Discharge Recent URI: viral conjunctivitis Hx of eye surgery endophthalmitis

EXAM Test vision and pupils Examine cornea for foreign body or ulcer Evert eyelids Foreign body Ophthalmoscopy If slit lamp available: Examine anterior chamber and assess depth Stain cornea with fluorescein and examine with blue light Looking for dendrite or corneal abrasion Check intra-ocular pressure Normal is 10-20 mmHg

Pattern of Redness Ciliary injection: redness most prominent around peripheral cornea. Iritis, acute glaucoma Conjunctival injection: Diffuse redness of entire conjunctiva Conjunctivitis Subconjunctival hemorrhage: thin continuous layer of BRB over white sclera

Conjunctival Injection Subconjunctival Hemorrhage Ciliary Injection http://www.slideshare.net/troypenn/ophthalmology-board-review-emergency-medicine-2014 http://www.haydenlasik.com/eye-conditions.html

Important points for red eye If patient has decreased vision, pain, or photophobia they will need urgent (same-day) referral to ophthalmology Not every red eye is “conjunctivitis” Never prescribe steroid eye drops unless ophthalmology has given the okay Only prescribe antibiotic drops for bacterial conjunctivitis: 2 red eyes, pus-like discharge, no change in vision, no pain/photophobia

HPI continued Patient woke up 5 days ago with red, throbbing, watery left eye. He reports photophobia and blurry vision of his left eye only. No trauma to eye. Not a contact lens wearer. He has had one similar episode in the past affecting his other eye. He has used OTC eye artificial tears and ibuprofen which has not significantly improved pain/redness. Associated symptoms include left –sided temporal headache, sore throat, subjective fever/chills, diffuse myalgias.

Social PMH ROS PSH: None Medications: None Allergies: None FH: no alcohol/tob/drugs Security guard One sexual partner, may have had an STD ROS Positive: fatigue, fever, weakness, sore throat, muscle aches, headache, cough Negative: painful urination, genital lesions/discharge, joint pain/stiffness PMH DM2 HTN Diverticulitis Previous episode red eye PSH: None Medications: None Allergies: None FH: Dad – DM2, cancer Mom: DM2, cancer No hx rheumatologic diseases  

Physical Exam Vitals: T 98.5 °F, HR 105, BP 164/104 mmHg, RR 18, SpO2 97 % General: Well-developed, NAD HEENT: Normocephalic and atraumatic. Cardiovascular: Normal rate, regular rhythm, no murmurs Pulm: CTAB, no wheezes/crackles/rhonchi Abdomen: normal active BS, soft, NTTP Extremities: +2/4 radial and DP pulses, no edema, no cyanosis Skin: warm, dry, no rashes Neuro: A&O x 3, no neuro deficits

Eye Exam IOP: OD 13, OS 10 Vision without correction OD 20/20, OS 20/25 R eye: PERRL, no discharge/injection/foreign bodies, no lesions with L eye: PERRL, serous discharge, no foreign body, + ciliary injection. Slit lamp: cells and flare, inferior fine keratic precipitates No lesions appreciated with fluorescein stain.

Work-up in ED CBC: CMP ESR 55 CXR – negative for acute process WBC 13.0 Hgb 15.6 Hct 43.3 187 CMP Na 134 K 4.3 Cl 99 Bicarb 23 Glucose 478 AST/ALT 30/35 Calcium 10.0 Albumin 3.9 ESR 55 CXR – negative for acute process

Anterior Uveitis (Iritis/Iridocyclitis)

Background Most common form of intraocular inflammation and painful red eye Inflammation of the anterior portion of the uvea or middle portion of the eye. Anterior portion includes iris and ciliary body. Iritis: Inflammation of the iris Iridocyclitis: Inflammation of the iris and the ciliary body Subdivided into 2 broad categories: granulomatous and non-granulomatous

Granulomatous Non-granulomatous More likely to be a systemic disease process Syphilis, Lyme disease, TB, Sarcoidosis Can be bilateral Non-granulomatous Idiopathic, associated with HLA-B27 allele, trauma, JIA Unilateral

Symptoms Visual acuity normal or slightly decreased Ciliary injection Eye pain: dull and aching Pain may be referred to temple/peri-orbital region Consensual photophobia Pain in affected eye when light shone in opposite eye Sometimes constricted pupil

Signs Low IOP most common Cells and flare in anterior chamber: Breakdown of blood-ocular barrier 2/2 inflammation WBC and protein accumulation in aqueous humor Keratic precipitates: Clusters of WBC on the endothelium Non-granulomatous Stellate-shaped: Uniformly spread over entire corneal epithelium Herpetic, CMV Fine: small, inferior half of cornea; idiopathic, HLA-B27 associated uveitis, trauma, JIA Granulomatous: “Mutton-fat”, large and greasy appearance Located mostly on inferior cornea

Cell and Flare https://dailyem.wordpress.com/2013/01/14/the-slit-lamp-exam-in-plain-language-for-ed-folk/ http://www.rootatlas.com/wordpress/video/209/cell-and-flare-photo/

Stellate KPs http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855658/figure/F0006/

Fine KPs http://imgkid.com/nongranulomatous-uveitis.shtml

Granulomatous KPs http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855658/figure/F0009/

Differential Diagnosis Posterior uveitis with spillover into anterior chamber Traumatic iritis Contact Lens-associated red eye Ocular Rosacea Posner-Schlossman syndrome Recurrent episodes high IOP and minimal inflammation Tumor Young: retinoblastoma Elderly: lymphoma All: metastatic disease Infectious endophthalmitis

Etiology Idiopathic: 30% of cases Infectious causes: Herpes zoster, herpes simplex, CMV, toxoplasmosis, syphilis, tuberculosis, Lyme dz, West Nile virus, Leprosy, HIV-1 Systemic inflammatory diseases: Spondyloarthritis, sarcoidosis, JIA, psoriatic arthritis, IBD, multiple sclerosis, Behcet’s disease, SLE, systemic vasculitis, Sjogren’s Drugs Rifabutin, Cidofovir, fluoroquinolones, bisphosphonates, cancer immunotherapy

Work-up/Diagnosis Detailed history and ROS Ask about ocular trauma, back stiffness, joint pain, rashes, dysuria, STDs, TB exposure, bloody diarrhea Ocular exam including IOP and slit-lamp exam Anterior chamber with cells and flare, KPs Lab work No lab work if: 1st episode, mild, unilateral, non-granulomatous, H&P not suggestive of systemic disease, findings classic for a specific diagnosis If bilateral, granulomatous, recurrent, and history is nonspecific then consider: RPR or VDRL, FTA-ABS, PPD, CXR, ACE, Lyme titer, ESR, HLA-B27

Treatment Initiate therapy within 24 hours Topical glucocorticoids Prednisolone acetate 1% Long-acting cycloplegic to help relieve pain and photophobia Cyclopentolate, scopolamine, or atropine Treat underlying cause Uveitis that is resistant to topical therapy: oral glucocorticoids, immunomodulators (methotrexate, azathioprine, infliximab)

Back to our patient Evaluated by ophthalmology the same-day and diagnosed with 2nd episode iridocyclitis Prescribed: prednisolone acetate 1% drops 4 times daily RTC within 1 week Work-up so far is negative: CXR, RF, HLA-B27, ACE, ANA, VDRL, FTA-ABS

References http://www.us.elsevierhealth.com/media/us/samplechapters/9780443101120/9780443101120.pdf The Red Eye, Chapter 4 Up-To-Date Uveitis: Etiology, clinical manifestations, and diagnosis Uveitis: Treatment Evaluation of the red eye Emedicine Uveitis, Anterior, Nongranulomatous Clinical Presentation Uveitis, Anterior, Granulomatous Clinical Presentation