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Home , Conjunctivitis, Uveitis

series • EDUCATION

Unilateral Eye series – 16

Chris Hodge, BAppSc, DOBA, is Research Director, The Eye Institute, Chatswood, New South Wales. Anthony Dunlop, MBBS, FRANZCO, FRACS, DA (UK), is an ophthalmic surgeon, Newcastle, and The Eye Institute Chatswood, New South Wales.

Case history Question 1 Question 6 Jason, 25 years of age, presents with Describe the differential diagnoses. What is the treatment for Jason’s ocular con- a 3 day history of pain ‘like bruising’ dition and general condition? and redness in his right eye. Initially Question 2 mild, the symptoms have steadily What examination findings and tests will help worsened and Jason feels his vision has now become affected. Reading is to differentiate these conditions? particularly uncomfortable and he notes that bright lights immediately Question 3 intensify the pain. There has been no Is Jason’s history of important to obvious discharge from the eye apart your diagnosis? from occasional tearing due to the light sensitivity. Jason’s medical Question 4 history is unremarkable apart from a chronic sore lower back. On Investigational X-ray results describe inflam- observation, the eye is severely mation of the sacroiliac joints. What is your injected around the limbal area. There diagnosis? is also numerous small to medium sized deposits in the lower area of the Question 5 anterior chamber. The is smaller than in his left eye. Are any further tests required? Figure 1. Severe limbal injection

Vision can also be affected in severe cases. patient will complain of pain, extreme photo- FEEDBACK sicca (dry ) is a rela- phobia and sudden deterioration of vision. tively common condition. On presentation The eye will be injected around the limbus. Answer 1 the patient will complain of grittiness, excess The pupil will be semi dilated and often unre- The presentation of a unilateral, painful red tearing, and red eyes, with active to light. Vision is affected by the eye can indicate the presence of several con- symptoms worse later in the day, or in hot or presence of severe corneal oedema. ditions. These may include bacterial dry conditions. This condition rarely signifi- is an intraocular that , corneal or intraocular inflamma- cantly threatens sight. involves the uveal tract (, and tion, ocular foreign body and acute angle An ocular foreign body will cause localised ). Uveitis can be further classified closure . Although commonly bilat- irritation and inflammation. Patients will com- depending on which structures are affected. eral in presentation, bacterial conjunctivitis monly produce excessive tearing as a result Anterior uveitis, involving the iris and occa- may present in one eye. The patient will gen- of the irritation. Similarly, the patient gener- sionally also the anterior part of the ciliary erally complain of a red, irritable eye. Purulent ally complains of light sensitivity. The vision body, will develop over several days begin- discharge is the hallmark of a bacterial infec- may or may not be affected. ning with general sensitivity and progressing tion. The patient may complain of photo- Acute angle closure glaucoma is charac- to photophobia, pain, redness over the ciliary phobia if there is associated punctuate terised by a sudden and severe increase in body (Figure 1) and visual loss. Keratic precip- epitheliopathy or peripheral corneal infiltrates. . On presentation the itates (KP), small cellular deposits from the

Reprinted from Australian Family Physician Vol. 33, No. 6, June 2004 443 Education: Unilateral red eye

corneal haze. Ciliary injection, the presence Approximately 30% of patients with ankylos- of KP, combined with the progression of ing spondylitis will experience an acute attack symptoms such as tenderness, photo- of uveitis (over 90% of these patients will be phobia and blurred vision suggests he is HLA-B27 positive). The association is weaker suffering an acute attack of uveitis. in conditions such as Crohn disease or psori- atic arthritis with 5% or less of patients Answer 3 suffering an attack of anterior uveitis at some In an active, young adult, back pain may be attrib- stage (only 50% of patients with these condi- uted to vigorous or excessive exercise or labour. tions will be HLA-B27 positive). The differential diagnosis may not be considered Answer 6 Figure 2. Keratic precipitates for many months or years in more subtle cases. Although almost 50% of uveitis cases are idio- The aims of ocular therapy are to resolve the anterior chamber on the posterior surface of pathic in origin, a large percentage are associated inflammation, relieve symptoms, return the , can be seen on close examina- with an underlying systemic condition. Although normal vision and prevent ocular scarring. tion (Figure 2). the precise link is uncertain, uveitis has been Although the course of an acute uveitis directly related to a group of autoimmune disor- attack is generally 2–6 weeks, referral to an Answer 2 ders called . Confirmation ophthalmologist within 24 hours is essential A thorough patient history should provide an of the ocular diagnosis of uveitis therefore to an optimum outcome. drops excellent platform for diagnosis. Visual acuity demands further investigation of the patient’s such as are the preferred initial assessment will help differentiate between general health especially given the previous therapy. Due to the possible side effects of conditions. Dry eye and conjunctivitis will not history of back pain. steroid drops it is important the patient is affect visual acuity, unless extreme. An acute carefully screened before and during treat- glaucoma attack will lead to corneal oedema Answer 4 ment. Possible short term complications that will cause an abrupt decrease in vision Inflammation of the spine and sacroiliac joints include acute intraocular pressure rise which and a fixed, semi dilated pupil. Inflammation are typical symptoms of ankylosing spondyli- can quickly lead to severe visual loss. Uveal from uveitis may lead to a constriction of the tis, a systemic rheumatic disorder. inflammation may lead to ciliary spasm and that could lead to posterior synechiae, Inflammation will cause stiffness and pain in cause periocular pain. Furthermore, the an adhesion between the anterior the lower spine; worse on waking and uveitis patient is at increased risk of posterior surface and iris. This will lead to an irregular relieved with activity. Other joints may be synechiae. Long acting cycloplegics such as and poorly reactive pupil. affected by inflammation, as can other and , work to relieve the On (and ophthalmoscopic) examina- organs such as the eyes, heart and lungs. pain and reduce the possibility of adhesions. tion, patients with conjunctivitis are injected Between 25–35% of patients with ankylosing If inflammation persists, periocular or oral peripherally over the globe and the posterior spondylitis will also experience an attack of steroids may be required. Treatment is surface of the lids, whereas those with acute anterior uveitis. tapered over 6 weeks despite symptomatic uveitis, will typically show an increase in Coexisting can differenti- and clinical quiescence to avoid bounce back redness toward the limbus (ciliary flush). In ate other systemic conditions that lead to inflammation. uveitis, KP are seen commonly in the mid or inflammation of the spine. , Treatment of the systemic findings is depen- inferior zone of the cornea. Small nodules which may follow an such as chlamy- dent on symptoms. NSAIDs may be used to (Koeppe nodules) may also appear at the dia or Gram negative dysentery, commonly treat sore or painful joints. If inflammation per- border of the pupil as a result of - displays a triad of symptoms of arthritis, con- sists, oral or injectable or tous uveitis. Dry eye changes will typically be junctivitis and . Skin lesions and nail immunosuppressants may be necessary. Care superficial. The examiner may notice dis- changes are associated with . should be taken due to the possible side effects rupted or inadequate tear film and small of these medications. Consultation with a erosions on the epithelial surface. In severe Answer 5 rheumatologist is required. Physical therapy to cases scarring may occur. In an acute glau- Most spondyloarthropathies are associated improve flexibility and maintain correct posture coma attack, the cornea will be hazy due to with the presence of HLA-B27 antigen. Blood is considered a useful adjunct to medical treat-

oedema, and visualisation of the anterior tests to confirm the presence of this gene ment in cases of . AFP chamber will be difficult. are not necessary to confirm diagnosis, Jason has no history of injury to suggest a however, it may provide information to the Correspondence foreign body, no purulent discharge and no probability of future uveitis attacks. Email: [email protected]

444Reprinted from Australian Family Physician Vol. 33, No. 6, June 2004