A 24-year-old man comes to the office due to vision disturbances. The patient has a history of ankylosing spondylitis and experienced severe pain and redness of the eyes a month ago. Evaluation at that time showed acute anterior uveitis and prednisolone eye drops were prescribed, which the patient still uses. The eye symptoms resolved within a week of treatment, but over the past several days the patient has had blurry vision and has needed more light to read. He has also experienced glare while driving at night. The patient has no other medical conditions, and his only other prescribed medication is naproxen as needed. Vital signs are within normal limits. Ocular examination shows nonerythematous conjunctiva, clear corneas, and no hypopyon or opacities of the lenses. Funduscopic examination is normal. The remainder of the physical examination, including neurologic examination, shows no abnormalities. Which of the following is the most appropriate next step in management of this patient?

Question

A 24-year-old man comes to the office due to vision disturbances.  The patient has a history of ankylosing spondylitis and experienced severe pain and redness of the eyes a month ago.  Evaluation at that time showed acute anterior uveitis and prednisolone eye drops were prescribed, which the patient still uses.  The eye symptoms resolved within a week of treatment, but over the past several days the patient has had blurry vision and has needed more light to read.  He has also experienced glare while driving at night.  The patient has no other medical conditions, and his only other prescribed medication is naproxen as needed.  Vital signs are within normal limits.  Ocular examination shows nonerythematous conjunctiva, clear corneas, and no hypopyon or opacities of the lenses.  Funduscopic examination is normal.  The remainder of the physical examination, including neurologic examination, shows no abnormalities.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d589_890c_bc81_4b478123ff25_MD0003_00 This patient has developed impaired vision while receiving glucocorticoid eyedrops (ie, prednisolone), suggesting possible steroid-induced open-angle glaucoma (OAG). OAG is a type of optic neuropathy associated with increased intraocular pressure (IOP). Topical glucocorticoid eyedrops and systemic glucocorticoids can raise IOP due to decreased outflow of aqueous humor via drainage channels in the anterior chamber, possibly worsened by the swelling of structures (eg, choroid, lens) in the posterior chamber. OAG is characterized by insidious loss of peripheral vision related to atrophy of the optic nerve head; signs include enlargement of the optic cup and increased cup/disc ratio (ie, "cupping" of the optic disc), but this is a late finding and may not be immediately apparent. However, patients with steroid-induced OAG may also develop central blurriness early in the course due to corneal edema. Chronic use of glucocorticoids can also cause subcapsular cataracts, although this is not yet seen in this patient. Elevated IOP in OAG can be documented with tonometry. Tonometry measures deformation of the cornea in response to applied (mechanical or pneumatic) pressure. Patients with suspected OAG should also receive assessment of peripheral fields using automated test devices (manual visual field testing by opposition has low sensitivity for OAG). (Choice A) Fluorescein dye can be instilled onto the surface of the eye to facilitate inspection of the cornea in patients with an ocular foreign body, corneal abrasion, or keratitis. These conditions are typically associated with eye pain, irritation, tearing, or redness. (Choice B) Lumbar puncture for spinal fluid analysis is useful for assessing subarachnoid hemorrhage (eg, thunderclap headache, meningeal signs) or meningitis (eg, headache, fever, neck stiffness). This patient has painless vision loss and a normal neurologic examination, and spinal fluid analysis is not needed. (Choice C) MRI of the brain can detect signs of multiple sclerosis, which can cause ocular symptoms due to optic neuritis. However, optic neuritis presents with ocular pain, acute vision loss, and an afferent pupillary defect. (Choice D) Untreated steroid-induced OAG can lead to permanent vision loss and therefore needs careful confirmation. Observation without testing is not appropriate. Educational objective: Topical glucocorticoid eyedrops and systemic glucocorticoids can raise intraocular pressure (IOP), leading to open-angle glaucoma (OAG). OAG is usually characterized by insidious loss of peripheral vision, and some patients with steroid-induced OAG may develop central blurriness due to corneal edema. IOP can be measured with tonometry. References: Steroid-induced glaucoma: an avoidable irreversible blindness. (http://www.ncbi.nlm.nih.gov/pubmed/28924342)

A 24-Year-Old Man Comes to the Office Due to Vision