Red Eye Practice Station 2

Presenting complaint:

• 2 day history of increasing right eye redness.
• No identifiable trigger that he knows of. It just came on suddenly during lunch 2 days ago.
• Since then the pain and redness has got worse.
• He went to the pharmacist and has tried chloramphenicol drops but it hasn’t made any difference.
• The eye is painful, especially if he looks at lights, so much so he has been wearing sunglasses indoors.
• The vision in the right eye is also blurred.
• No discharge, nausea or vomiting, fever, itching or trauma.

Ideas, Concerns & Expectations (ICE):

• He wants pain relief and is worried he will go blind.

Ocular History:

• Nil, never had this before.
• Doesn’t wear glasses or contact lenses.
• No eye operations or drops.

Past Medical History, Drugs History & Allergies:

• Generally well in himself.
• No existing known medical conditions.
• No regular medications.
• No allergies.

Social History:

• Works in a bank.
• Plays badminton with friends.
• Went to Tenerife 2 months ago with the family.
• No unwell contacts.

Observations:

• Respiratory rate 18 breaths per minute.
• O2 sats 99% on air.
• Blood pressure 120/80.
• Heart rate 78 beats per minute.
• Temperature 37.7ºC.

General Examination

• Praveen is wearing black sunglasses & isn't keen to take them off due to pain, but he agrees to remove them for the examination.
• It was painful for him when testing pupils and trying to assess the fundus of the right eye.

Eye exam:

Give your diagnosis and explain your rationale:

• This is a first presentation of acute anterior uveitis.
• The patient has an acute onset red eye with pain, blurred vision and photophobia.
• The pupil is irregular due to synechiae which is a classical finding in uveitis.
• Furthermore there is ciliary flushing (circumlimbal injection) and keratic precipitates are described.
• All these findings give the diagnosis of acute anterior uveitis.

Name 3 triggers or systemic conditions linked to uveitis:

• Autoimmune - Rheumatoid arthritis, Ankylosing spondylitis, Systemic Lupus Erythromatosus, Juvenile Idiopathic Arthritis.
• Sarcoidosis
• Tuberculosis
• Trauma
• Post-operative
• Idiopathic
• Infective - often linked to herpes simplex or zoster infections
• Inflammatory bowel disease
• Many other options - too many to list here

How would you manage this patient given you are seeing them in a GP setting?

• Requires same day review in eye casualty by the ophthalmology team.

Describe in broad terms the initial management of anterior uveitis by the ophthalmologist (detailed regimes are not expected):

• Cycloplegia
• Steroid drops
• Typically the cycloplegia needs to be applied 3 times a day and the steroids are started hourly. Usually patients need review within 3 days to assess their response. At this point a tapering regime for the steroids may be initiated.

Why are these medications used?

• Cyclopentolate causes cycloplegia - paralysis of the ciliary muscles. This helps to break any synechiae but also stops the iris muscles contracting which causes pain in uveitis.
• Steroid drops reduce inflammation within the eye. Usually it is prescribed as a weaning regime.

Name 2 relatively common complications of uveitis and it’s treatment:

• Cataract ~ sometimes the inflammation within the eye itself can lead to cataract formation. Furthermore steroid eye drops increase the risk of cataract formation.
• Glaucoma ~ some people are steroid responders and their intra-ocular pressure can rise whilst using the steroid drops. If the pressure becomes too high it can damage the optic nerve leading to glaucomatous damage and vision loss.