Case 15: Red Eye. Expert comment by Sarah Maling

Thanks to everyone who contributed to the discussions about Ted a 31 year old man who had a unilateral red eye with visual blurring.

photo 4 

You can see the highlights of the discussion on Twitter in the storify.

This week’s question setter & expert was Ms Sarah Maling, Consultant Ophthalmologist & Clinical Teaching Fellow UCLMS. 

Information available at the start of the week:

Ted is a fit and healthy builder who works on site driving a van. He is in good health and taking no medications. He lives with his wife and 18 month old child. He smokes ten cigarettes per day and drinks two pints of beer on a Friday and Saturday night.

In A&E he has a red left eye with no discharge. Background light is uncomfortable and the eye is painful all the time. He does not wear glasses. He has no other complaints other than his back hurts a bit but he has put this down to extra weekend work on the building site.

Positive findings:

  • Vision is 6/12 in the left eye compared to 6/5 in the right. ( no improvement with pin hole.
  • The pupil in the left eye is an unusual shape.
  • There are white dots on the back of the inferior 1/3 of the cornea.
  • The view to the optic disc is clear and the optic disc is normal.

Question 1: What tests would you request in A&E to assist with diagnosis? 

Chest x-ray ( sarcoid and TB) Treponemal test ( Chlamydia), urine sample ( TINU – tbular interstitial necrosis and uveitis) and serum ACE (sarcoidosis) – all other tests should be done in uveitis clinic.

 Question 2. What are the white dots?

A Keratic precipitate (KPs). These are inflammatory cellular deposits on corneal endothelium. Acute KPs are white and round in shape whereas old KPs are faded and irregular in shape. Mutton-fat KPs are large in shape and are greasy-white in color and are formed from macrophages and epithelioid cells.

 Question 3. Why is the pupil a funny shape?

Inflammation in the eye results in increased fibrin in the anterior chamber of the eye resulting in adhesions between the iris and the anterior capsule of the lens.

 Question 4. What other eye related tests are important in this patient?

Intraocular Pressure (IOP) – inflammation can cause and increase in pressure. Steroid drops can cause and increase in pressure and synechiae can obstruct the drainage of aqueous and result in an increase in pressure.

OCT – macular oedema is a side effect of inflammation in the eye. If patients have a reduced vision and it is possible to view the macula an OCT will identify if there is any oedema.

Question 5. How would the eye be managed initially?

A Topical steroid drops ( ie dexamethasone 0.1%) These are given 1-2 hourly for the first week and then tapered over 6 weeks ( ie hourly 1/52, 2 hourly 1/52, qid 1/52, tid 1/52, bd 1/52 and od 1/52. Ideally IOP check at 1 week to ensure IOP not increased on drops. Dilating drops ( ie cyclopentolate 1%) tid for 1-2 weeks depending on response.

Question 6. What systemic medication might be required if topical medication does not work?

An immunosuppressive agents may be required when the disease is not responding to topical treatment or if it is occurring in both eyes, particularly in the back of both eyes.

First line immunosuppression is often steroids. Remember that long-term steroid use may produce side effects such as stomach ulcers, osteoporosis (bone thinning), diabetes, cataracts, glaucoma, cardiovascular disease, weight gain, fluid retention, sleep disturbance, mood change and Cushing’s syndrome. Usually other agents are started if it appears that patients need moderate or high doses of oral steroids for more than 3 months.

Other immunosuppressive agents that are commonly used include medications such as methotrexate, mycophenolate, azathioprine, and cyclosporine. These treatments require regular blood tests to monitor for possible side effects. In some cases, biologic response modifiers (BRM), or biologics, such as, adalimumab, infliximab, daclizumab, abatacept, and rituximab are used. These drugs target specific elements of the immune system. Some of these drugs may increase the risk of having cancer.

Question 7. What concerns might this patient have concerning his job and future with the above condition?

Uveitis treatment can be prolonged with mean duration of follow up 36.7 months. The systemic medications have many side effects that need to be carefully discussed with patients. Prolonged visual loss has been found in almost two thirds of patient with this diagnosis.  All conditions that affect the eyes and eye sight may impact on a patient’s ability to drive. This particular patient is young, a driver and works on a building site. He is used to good binocular vision. Immediate concerns might include his ability to work (safety on ladders, driving etc if loss of binocular single vision). Longer term he is likely to need follow up for more than 2 years and this will involve either days of work or more extended periods if the inflammation flares up resulting in significant loss of vision.

Expert Comment by Sarah Maling, Consultant Opthalmologist

This patient is likely to have idiopathic anterior uveitis but I would be concerned about the back pain in the history. Following a full examination to ensure that the inflammation was limited to the anterior chamber I would commence treatment. As the inflammation was unilateral I would treat topically with dexamethasone and cyclopentolate. Treatment with the steroid drop would be hourly for one week, 2 hourly for one week and then qid,tid,bd and od for the next 4 weeks.

The patient would ideally be reviewed at 1 week to check improvement of inflammation and no rise in intraocular pressure.

The ongoing management of this patient would depend on the improvement of inflammation on topical medication. Further investigations in anterior uveitis should be done in the confines of an uveitis clinic and not in A&E as blood test results such as HLA-B27 should be discussed with patients with a plan as to what they mean.

Idiopathic anterior uveitis is a fairly common diagnosis (US 8 per 100000) and accounts for 45 – 76% of causes of uveitis in different series. As shown above it is often recurrent. The treatment will always require a minimum of 6 weeks of topical medication and may well require further systemic medication.

The key learning points of this case are:

  • highlight uveitis and its systemic connections
  • highlight the treatments and the side effects that these have
  • highlight the impact that chronic eye conditions have on patients (work, driving, hospital visits) and emphasise that uveitis affects young people.
  • highlight the need to identify and treat conditions in an emergency setting but leave investigations to be done in settings that can support delivery of results to patients.

Resources:

  1. Degree, duration, and causes of visual loss in uveitis, O M Durrani, N N Tehrani, J E Marr, P Moradi, P Stavrou, P I Murray, Br J Ophthalmol 2004;88:1159–1162. doi: 10.1136/bjo.2003.037226
  2. Agrawal RV, Murthy S, Sangwan V, et al; Current approach in diagnosis and management of anterior uveitis. Indian J Ophthalmology. 2010 Jan-Feb; 58(1):11-9. Doi:10.4103/0301 – 4738.58468
  3. Jackson TL; Moorfields Manual of Ophthalmology, Mosby (2008)
  4. Guly CM, Forrester JV; Investigation and management of uveitis. BMJ. 2010 Oct 13;341:c4976. doi: 10.1136/bmj.c4976.
  5. Uveitis; NICE CKS, November 2009
  6. http://www.nei.nih.gov/health/uveitis/uveitis.asp#a

Further information about uveitis:

Uveitis is a general term describing a group of inflammatory diseases that produces swelling and destroys eye tissues. The term “uveitis” is used because the diseases often affect a part of the eye called the uvea. Nevertheless, uveitis is not limited to the uvea (choroid, ciliary body and iris). These diseases also affect the lens, retina, optic nerve, and vitreous, producing reduced vision or blindness.

Inflammation is the body’s natural response to tissue damage, germs, or toxins. It produces swelling, redness, heat, and destroys tissues as certain white blood cells rush to the affected part of the body to contain or eliminate the insult.

Uveitis may be caused by:

An attack from the body’s own immune system (autoimmunity).

Infections or tumors occurring within the eye or in other parts of the body.

Bruises to the eye (trauma).

Toxins that may penetrate the eye.

Diseases Associated with Uveitis

Uveitis can be associated with many diseases including:

  • AIDS,
  • Ankylosing spondylitis
  • Behcet’s syndrome
  • CMV retinitis
  • Herpes zoster infection
  • Histoplasmosis
  • Kawasaki disease
  • Multiple sclerosis
  • Psoriasis
  • Reactive arthritis
  • Rheumatoid arthritis
  • Sarcoidosis
  • Syphilis
  • Toxoplasmosis
  • Tuberculosis
  • Ulcerative colitis
  • Vogt Koyanagi Harada’s disease

What is Anterior Uveitis?

Anterior uveitis occurs in the front of the eye. It is the most common form of uveitis, predominantly occurring in young and middle-aged people. Many cases occur in healthy people and may only affect one eye but some are associated with rheumatologic, skin, gastrointestinal, lung and infectious diseases.

What is Intermediate Uveitis?

Intermediate uveitis is commonly seen in young adults. The center of the inflammation often appears in the vitreous. It has been linked to several disorders including, sarcoidosis and multiple sclerosis.

What is Posterior Uveitis?

Posterior uveitis is the least common form of uveitis. It primarily occurs in the back of the eye, often involving both the retina and the choroid. It is often called choroditis or chorioretinitis. There are many infectious and non-infectious causes of posterior uveitis.

What is Pan-Uveitis?

Pan-uveitis is a term used when all three major parts of the eye are affected by inflammation. Behcet’s disease is one of the most well-known forms of pan-uveitis and it greatly damages the retina.

Intermediate, posterior, and pan-uveitis are the most severe and highly recurrent forms of uveitis. They often cause blindness if left untreated.

How is Uveitis Treated?

Uveitis treatments primarily try to eliminate inflammation, alleviate pain, prevent further tissue damage, and restore any loss of vision. Some, such as using corticosteroid eye drops and injections around the eye or inside the eye, may exclusively target the eye whereas other treatments, such immunosuppressive agents taken by mouth, may be used when the disease is occurring in both eyes, particularly in the back of both eyes.

Long-term steroid use may produce side effects such as stomach ulcers, osteoporosis (bone thinning), diabetes, cataracts, glaucoma, cardiovascular disease, weight gain, fluid retention, and Cushing’s syndrome. Usually other agents are started if it appears that patients need moderate or high doses of oral steroids for more than 3 months.

Other immunosuppressive agents that are commonly used include medications such as methotrexate, mycophenolate, azathioprine, and cyclosporine. These treatments require regular blood tests to monitor for possible side effects. In some cases, biologic response modifiers (BRM), or biologics, such as, adalimumab, infliximab, daclizumab, abatacept, and rituximab are used. These drugs target specific elements of the immune system. Some of these drugs may increase the risk of having cancer.

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