A 32-year-old woman comes to the emergency department due to right eye pain and redness. The symptoms started 2 days ago and have progressively worsened. The patient notes, "My right eye is blurry, and it hurts when I look at bright light." She has had no eye trauma or similar symptoms in the past. She has no prior medical conditions but has had several weeks of nonproductive cough. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Right eye examination reveals conjunctival injection, particularly around the cornea. The right pupil is constricted and reacts sluggishly to light. Left eye examination is normal, but penlight examination of the left eye results in right eye discomfort. The lungs are clear to auscultation. The abdomen is soft and nontender with no hepatosplenomegaly. Skin examination shows several small, tender nodules on the shins. Chest radiography reveals bilateral hilar lymphadenopathy. Which of the following is the most likely cause of this patient's ocular symptoms?

Question

A 32-year-old woman comes to the emergency department due to right eye pain and redness.  The symptoms started 2 days ago and have progressively worsened.  The patient notes, "My right eye is blurry, and it hurts when I look at bright light."  She has had no eye trauma or similar symptoms in the past.  She has no prior medical conditions but has had several weeks of nonproductive cough.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  Right eye examination reveals conjunctival injection, particularly around the cornea.  The right pupil is constricted and reacts sluggishly to light.  Left eye examination is normal, but penlight examination of the left eye results in right eye discomfort.  The lungs are clear to auscultation.  The abdomen is soft and nontender with no hepatosplenomegaly.  Skin examination shows several small, tender nodules on the shins.  Chest radiography reveals bilateral hilar lymphadenopathy.  Which of the following is the most likely cause of this patient's ocular symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c186_7e50_8f63_db073be9b5cb_MD0005_00 Anterior uveitis is characterized by inflammation of the iris and ciliary body. Most cases are due to an underlying infection (eg, AIDS) or systemic inflammatory disease. Manifestations typically include: iris and ciliary body Erythema at the limbus (junction of cornea and sclera) A constricted pupil Blurred vision Moderate eye pain Patients with suspected anterior uveitis should be referred to an ophthalmologist for diagnosis. Investigation of the underlying cause is then required. This patient with bilateral hilar lymphadenopathy and erythema nodosum (painful shin lesions) likely has anterior uveitis due to sarcoidosis. Sarcoidosis is a systemic inflammatory disease characterized by multiorgan noncaseating granulomas. Most patients with sarcoidosis seek medical attention due to pulmonary disease (eg, cough, dyspnea), but extrapulmonary manifestations in the eyes, skin, heart, and joints are common. Ocular disease occurs in approximately 25% of patients with sarcoidosis at some point during illness and is the presenting symptom in 5% of cases. erythema nodosum (Choice A) Angle-closure glaucoma usually causes blurred vision and conjunctival erythema. However, it is most common in elderly patients and is typically associated with severe eye pain, a mid-dilated pupil, headache, and nausea and vomiting. This young patient with moderate eye pain, a constricted pupil, and focal erythema at the limbus is more likely to have uveitis. (Choice C) Bacterial conjunctivitis typically causes diffuse conjunctival erythema and purulent discharge. This patient with no discharge, erythema at the limbus, and a constricted pupil is more likely to have uveitis. (Choice D) Endophthalmitis is a bacterial or fungal infection of the intraocular cavities, which usually causes decreased visual acuity, aching of the affected eye, and conjunctival injection. Most patients have a severe underlying illness (eg, hospitalization with a central catheter) or recent eye surgery. This healthy young patient is unlikely to have endophthalmitis. (Choice E) Sarcoidosis can cause keratoconjunctivitis sicca, which is characterized by dry eyes and a sensation of ocular grittiness. However, this patient with a constricted pupil, eye pain, and limbus erythema is more likely to have anterior uveitis. Educational objective: Anterior uveitis typically presents with erythema at the limbus, a constricted pupil, blurred vision, and moderate eye pain. Sarcoidosis is a particularly common cause of anterior uveitis and should be suspected when other characteristic sarcoid findings (eg, bilateral hilar lymphadenopathy, erythema nodosum) are present. References: Sarcoidosis and uveitis. (http://www.ncbi.nlm.nih.gov/pubmed/24704868) Ocular sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/22595776) Extrapulmonary manifestations of sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/23597964)

A 32-Year-Old Woman Comes to the Emergency Department Due to Right