Chief complaint
Ms. AM (a 75-year-old female) had been experiencing gradually blurring vision for the past week with foreign body sensation. Red eye OS. She denied other symptoms or injury. Artificial tears only.
History
Past ocular history: S/P pseudophakia 1990. YAG OD 1994.
Past medical history: Unremarkable.
Exam
|
OD |
OS |
|
Best corrected visual acuity: |
20/25 |
20/40 |
|
External: |
|
1+ diffuse conjunctival injection |
|
Slit lamp: |
within normal limits |
 |
horizontal parallel folds (series of keratic precipitates [KPs] lined up); mild anterior chamber reaction; fundus within normal limits; 3 upper lid lashes rubbing cornea
[view video] |
|
|
IOPs (applanation tonometry): |
16mmHg |
16mmHg |
|
Dilated fundus exam: |
unremarkable |
unremarkable |
Assessment:
Corneal edema and secondary iritis OS; trichiasis OS
Plan/Treatment
- Epilation of lashes
- Lotemax ophthalmic susp q4h OS
- Follow-up in 2 days: 50% improvement
- Resolved in 1 week
