In order to manage AU properly, you must first classify it correctly:

Case 1
Case 2
Case 3

	URL: http://www.opt.indiana.edu/ce/antuve/cases.htm Revised: April 10, 2006
	IU Optometry home page: http://www.opt.indiana.edu/ Comments (content): Dr. Julie Torbit at jtorbit@indiana.edu Comments: Web Administrator Page design and coding: Terri Greene Copyright © 2006, The Trustees of Indiana University

Medical history is significant for rheumatoid arthritis and Sjögren's syndrome. History of metaphopsia OD; previously taking Plaquenil but discontinued when pigmentary changes were noted in OD macula and decreased waveforms on the multifocal ERG.

Chief complaint of her right eye being red eye for two days; sensation of something in her eye.
VA 20/150 OD PH-NI, 20/20 OS

Exam revealed:

• 3+ circumlimbal hyperemia OD
• 2+ cells/1+ flare OD
• 2+ to 3 endothelial KPs OD
• 2+ corneal edema and striae
• IOPs: 17 OD, 20 OS
• Internal exam unremarkable expect for macular pigmentary changes

What do you think is the cause?

Assessment

Probable herpetic endothelitis with iritis (zoster vs. simplex--no previous history of either) OD; (-) epithelial disease noted.

Plan

• 2 drops in-office instillation of Atropine 1% OD
• Pred Forte q 2 hours OD
• Watch closely for epithelial disease
• RTC in 2 days

Follow-Up (2 days later)

• Findings: No anterior chamber reaction OD, significantly improved K edema, 1+ KPs OD
• Assessment: Resolving herpetic endothelitis OD
• Plan: Decrease Pred Forte to qid OD
• RTC in 4-5 days

Follow-Up (5 days later)

• Minimal K swelling, no anterior chamber reaction OD
• Assessment: Essentially resolved herpetic endothelitis OD
• Plan: Decrease Pred Forte to bid x 3 days, qd x 3 days, then d/c
• RTC in 2 weeks

Patient lost to follow-up.

Complaints of large blotches in vision OS x 1 day, (-) flashes, (-) floaters.

History of HTN (controlled), gout with recent high uric acid levels, and lattice degeneration without holes OU.

Findings:

• VA 20/20 OD, 20/25 OS
• Trace conj. injection OU
• Trace cells and flare OS
• KPs OS
• DFE--1+ vitreal cells with heavy vitreal condensation
• OS; PVD OS

What is the possible cause of this anterior uveitis?

Assessment

Iritis/vitritis secondary to recent uric acid spike.

Plan

• Pred Forte qid OS
• RTC in 1 week for follow-up

Patient lost to follow-up.

Footnote: Uveitis was once thought to be strongly associated with gout; however, studies have shown it is not. Berman (1985) looked at 69 patients with gout and found none with uveitis. The association, though, continues to be reported in the literature.

Patient complains of pain and photophobia for 5 days in OS. History of anterior uveitis OD twice in past. No history of systemic diseases. Patient takes no medicines.

VAs:
20/40 OD, PH--NI
20/150 OS, PH--NI

Pupils:
Fixed and irregular pupils secondary to posterior synechiae OU

Cornea:
Grade 1+ pigmented KPs OD
Grade 3+ mutton fat KPs OS

Anterior Chamber:
Clear OD
Trace flare OS

IOPs: 16 OD, 18 OS

Assessment:
Chronic, granulomatous uveitis OS > OD

Plan:

• Econopred Plus 1% q hour OS
• Homatropine 5% tid OS
• Ibuprofen q 4 hours for pain
• Following tests were ordered: chest X-ray, CBC with differential, ACE, ANA, FTA-ABS, RPR, PPD, ESR, C-reactive protein
• RTC in 2 days

Follow-Up (2 days later)

• VAs: OD 20/30--PH-NI, OS 20/70--PH-NI
• Irregular pupils still present OU
• KPs still present OU
• A/C clear OD, trace flare OS
• IOPs: 16 OD, 18 OS
• Unable to dilate the pupil with a pledget of 10% Phenylephrine
• Assessment: Resolving anterior uveitis OS, unable dilate pupils secondary to posterior synechiae
• Plan: Decrease Econopred Plus 1% to q 2 hours; continue Homatropine tid
• RTC in 4 days

Follow-Up (4 days later)

• Patient reports more pain behind left eye
• VAs: 20/30 OD, 20/160 OS, PH--20/100
• Refraction OD 20/20, OS--NI (20/160)
• SLEx: Cornea--significant punctate staining OS; KPs still present; A/C--clear OS, OD; synechiae OU
• IOPs: 22 OD, 32 OS
• Assessment: Stable anterior uveitis OS, elevated IOP OS > OD, medicamentosa OS
• Plan:
  • Decrease Econopred Plus 1% to qid OS
  • Continue Homatropine tid OS
  • Add Alphagan-P tid OS
  • Add non-preserved artificial tears qid or as needed for irritation
• RTC in 3 days

Follow-Up (3 days later)

• Patient has complaints of flashes/floaters x several days
• Patient started oral steroids (40mg x 2 wks, then 20mg x 1 wk, then 20mg q other day x 1 wk, then discontinue) given by MD 2 days ago
• Appointment with rheumatologist in 1 month
• VAs: 20/30 OD, PH--NI; 20/50 OS, PH--20/40
• SLEx: A/C clear OD, OS; pigmented KPs OU; mild SPK OS
• IOPs: 18 OD, 22 OS
• Internal exam: No fundus view secondary to fixed pupils (unable to dilate again w/10% Ph), B scan normal OS
• Assessment: Resolving anterior uveitis OS with decreased IOP, resolving medicamentosa OS
• Plan:
  • Decrease Econopred to bid x 1 week, then qd x 1 week; then q other day x 1 week; then d/c
  • Decrease Alphagan-P to bid
  • Continue non-preserved artificial tears
  • Discontinue Homatropine
  • RTC in 2 weeks

Patient lost to follow-up.

Case 3 Lab Test Results Low Hemoglobin and Hematocrit Negative RPR Elevated SED rate Positive ANA Speckled pattern was abnormal--can indicate Lupus, Mixed Connective Tissue Disease (MCTD), Scleroderma, and Sjögrens Negative antibody testing for Sjögrens (Anti-SS-A/Anti-SS-B), MCTD (Anti-RNP), and Scleroderma (Scl-70 Ab) Negative Anti-DNA (2/3 of Lupus pts are +) and Smith Antibodies (rarely elevated in disorders other than Lupus) X-ray of spine: no focal abnormality of dorsal spine X-ray of chest: fibrosis and chronic interstitial lung disease suggestive of sarcoidosis Patient was simply diagnosed with a nonspecific collagen vascular disease and then lost to f/u Would have been nice to have had an ACE level, serum lysozyme, BUN, Kviem-Siltzbach skin test, and possibly a lung biopsy. Serum Lysozyme Enzyme produced by a sarcoid granulomas Elevated in active sarcoid disease May be elevated in other diseases BUN--serum chemistries that includes calcium, liver enzymes, and creatinine Kviem-Stilzbach Skin Test Human sarcoidal tissue is injected intradermally into the forearm 4-6 weeks later the area is biopsied to check for a nodule revealing a noncaseating granuloma Test is approximately 75% positive for sarcoidosis Test has a low FP rate for sarcoidosis

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