A 35-year-old man comes to the emergency department with a 3-day history of pain and redness in the left eye. He is a school bus driver and was exposed to a child with pink eye. The patient has no associated fever, headache, nasal congestion, or sore throat. However, he has experienced episodic abdominal discomfort and diarrhea over the past several months. The patient has no other medical problems and takes no medications. Family history is notable for glaucoma in his mother. Ocular examination findings are shown in the exhibit. During the examination, the patient keeps the eye closed and says, "It is painful to look at the light." There is increased tearing from the left eye but no mucoid or purulent discharge. Right eye examination is normal. Visual acuity is 20/50 in the left eye and 20/20 in the right eye. There is no nasal discharge and the pharyngeal mucosa is not erythematous. An aphthous ulcer is present on the buccal mucosa. Abdominal examination shows tenderness in the right lower quadrant on deep palpation. The remainder of the physical examination is normal. Which of the following is the most likely cause of this patient's eye symptoms?

Question

A 35-year-old man comes to the emergency department with a 3-day history of pain and redness in the left eye.  He is a school bus driver and was exposed to a child with pink eye.  The patient has no associated fever, headache, nasal congestion, or sore throat.  However, he has experienced episodic abdominal discomfort and diarrhea over the past several months.  The patient has no other medical problems and takes no medications.  Family history is notable for glaucoma in his mother.  Ocular examination findings are shown in the exhibit.  During the examination, the patient keeps the eye closed and says, "It is painful to look at the light."  There is increased tearing from the left eye but no mucoid or purulent discharge.  Right eye examination is normal.  Visual acuity is 20/50 in the left eye and 20/20 in the right eye.  There is no nasal discharge and the pharyngeal mucosa is not erythematous.  An aphthous ulcer is present on the buccal mucosa.  Abdominal examination shows tenderness in the right lower quadrant on deep palpation.  The remainder of the physical examination is normal.  Which of the following is the most likely cause of this patient's eye symptoms?

Quizplus · Accepted Answer

11ec25c8_d493_68aa_bc81_bd6469032f03_MD0003_00 This patient has anterior uveitis, which presents with a painful, red eye associated with photophobia, tearing, and diminished visual acuity. The uvea is the tissue layer between the cornea/sclera and the retina; the anterior uvea consists of the iris and ciliary body and the posterior uvea consists of the choroid. Anterior uveitis is inflammation of the anterior uveal tract and is sometimes termed "iritis" (or "iridocyclitis" if the ciliary body is involved). It is much more common than posterior uveitis, which involves the choroid. Examination findings in anterior uveitis can include hyperemia concentrated at the junction of the sclera and cornea (ciliary flush), pupillary constriction, a hazy "flare" in the aqueous humor, and layering of white cells in the anterior chamber (hypopyon). Examination findings Anterior uveitis is most often idiopathic or traumatic, but it can be associated with systemic inflammatory diseases such as certain infections (eg, herpesviruses, toxoplasmosis), sarcoidosis, spondyloarthritis (eg, ankylosing spondylitis, reactive arthritis), and inflammatory bowel disease. This patient's oral aphthous ulcer, abdominal tenderness, and intermittent gastrointestinal symptoms suggest possible Crohn disease. (Choice A) Acute angle-closure glaucoma can cause a red, painful eye with diminished visual acuity. However, it is more common in older patients (predominantly age 55-70), and most patients have headache, nausea, and vomiting. (Choices C and E) Bacterial conjunctivitis is characterized by conjunctival edema and hyperemia and a purulent discharge, whereas viral conjunctivitis (pink eye) causes conjunctival redness with a watery or mucoid discharge. Patients with either type of conjunctivitis may also experience morning mattering of the lids. This patient has dilation of the conjunctival vessels, but his decreased visual acuity and photophobia are not consistent with conjunctivitis. (Choice D) Episcleritis is characterized by acute redness and tearing with injection of conjunctival and episcleral vessels. Patients may have mild irritation, but overt pain and diminished visual acuity, as seen in this patient, are not consistent with episcleritis. Educational objective: Anterior uveitis (iritis and iridocyclitis) is characterized by a painful, red eye with tearing and decreased visual acuity. Examination findings include ciliary flush, pupillary constriction, a hazy "flare" in the aqueous humor, and hypopyon. Anterior uveitis is most often idiopathic or traumatic but can be associated with systemic inflammatory diseases such as certain infections, sarcoidosis, spondyloarthritis, and inflammatory bowel disease. References: Diagnosis and management of red eye in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/20082509)

A 35-Year-Old Man Comes to the Emergency Department with a 3-Day