A 29-year-old man comes to the office for evaluation of blurred vision and right eye pain. The pain increases when he is in bright light. The patient also has a yearlong history of generalized fatigue, sleep problems, back pain, and occasional heel pain. He has no recent illnesses. Medical history is notable for obesity and hypertension treated with lisinopril and chlorthalidone. The patient is monogamous. He lives in Texas and has not traveled outside the state. Temperature is 36.8 C (98.2 F), blood pressure is 134/88 mm Hg, and pulse is 80/min. Examination of the right eye shows redness of the sclera, which is most prominent at the junction between the cornea and the sclera. The right pupil is constricted, and there is photophobia with penlight examination. The left eye is normal. There are no skin lesions. In addition to treating this patient's eye condition, what additional workup is needed?

Question

A 29-year-old man comes to the office for evaluation of blurred vision and right eye pain.  The pain increases when he is in bright light.  The patient also has a yearlong history of generalized fatigue, sleep problems, back pain, and occasional heel pain.  He has no recent illnesses.  Medical history is notable for obesity and hypertension treated with lisinopril and chlorthalidone.  The patient is monogamous.  He lives in Texas and has not traveled outside the state.  Temperature is 36.8 C (98.2 F), blood pressure is 134/88 mm Hg, and pulse is 80/min.  Examination of the right eye shows redness of the sclera, which is most prominent at the junction between the cornea and the sclera.  The right pupil is constricted, and there is photophobia with penlight examination.  The left eye is normal.  There are no skin lesions.  In addition to treating this patient's eye condition, what additional workup is needed?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d301_3039_bc81_d5e4a11c23ad_MD0003_00 This patient has anterior uveitis with eye pain, photophobia, decreased visual acuity, and scleral hyperemia at the corneal margin (ie, ciliary flush). Anterior uveitis is inflammation of the anterior uveal tract (ie, iris, ciliary body) and is sometimes termed iritis (or iridocyclitis if the ciliary body is involved). Other common findings include pupillary constriction, a hazy flare in the aqueous humor, and layering of white cells in the anterior chamber (hypopyon). The diagnosis can be confirmed on slit-lamp examination. ciliary flush Anterior uveitis can be idiopathic but often occurs in association with systemic inflammatory disorders. Further evaluation depends on the presence of associated features that could suggest a systemic disease: No evidence of systemic disease: Chest x-ray and serum rapid plasma reagin should be obtained because both sarcoidosis and syphilis can be silent. Evidence of systemic symptoms: For back pain or enthesitis, x-ray of the sacroiliac joints should be obtained to rule out spondylarthritis (eg, ankylosing spondylitis). This patient also has chronic back pain and possible enthesitis (ie, Achilles tendonitis/heel pain), findings suggestive of ankylosing spondylitis. Specific x-ray findings include widening of the sacroiliac joints and subchondral sclerosis. Some experts also advise human leukocyte antigen B27 typing, although it has low specificity. (Choices A and D) Anti-Ro/SSA antibodies are seen in Sjögren syndrome, which can cause dry eyes and corneal ulceration. Rheumatoid factor is associated with rheumatoid arthritis, which can cause episcleritis (acute redness and mild irritation) and scleritis (severe ocular pain with diffuse scleral erythema and edema). However, these conditions are not commonly associated with uveitis. In addition, although rheumatoid arthritis can affect the cervical spine, back pain is unusual. (Choice B) Lyme disease is occasionally associated with uveitis. However, this patient has no rash to suggest the disease, and the causative organism (Borrelia burgdorferi) is not endemic to Texas and the Southcentral United States. (Choice C) MRI is used in the evaluation of multiple sclerosis, which is occasionally associated with uveitis, although optic neuritis is more common. However, this patient has no neurologic findings (eg, sensory/motor deficits) to suggest multiple sclerosis, and his musculoskeletal symptoms are more suggestive of ankylosing spondylitis. Educational objective: Anterior uveitis often occurs in association with systemic inflammatory disorders, in particular spondylarthritis (eg, ankylosing spondylitis). Patients with uveitis and features suggesting ankylosing spondylitis (eg, chronic back pain, enthesitis) should undergo x-ray of the pelvis/sacroiliac joints and possibly human lymphocyte antigen B27 typing.

A 29-Year-Old Man Comes to the Office for Evaluation of Blurred