Today we discussed a case of a young male sex-worker presenting with 6 weeks of bilateral red eyes, vision loss, and photophobia--without foreign body sensation who was initially treated for conjunctivitis in 2 previous ED visits, but was ultimately found to have iritis/uveitis from syphilis.
Some learning points from the case:
1) When encountering the red eye, some red flags that should prompt urgent or emergent ophthalmology referral include:
- vision loss
- severe ocular pain
- significant foreign body sensation (except initial presentation of a simple corneal abrasion) or opacity that stains with fluorescein as these are signs of an active corneal process
- unilateral red eye in a generally uncomfortable patient with nausea and vomiting (suggestive of acute angle closure glaucoma)
- finding of hypopyon (WBCs in anterior chamber; associated with endophthalmitis and infectious keratitis) or hyphema (RBCs in the anterior chamber associated with trauma, retinal detachment, and inflammation)
2) A sign that a patient has iritis is a history of photophobia WITHOUT objective foreign body sensation (WITH would increase your suspicion for a corneal process). Objective foreign body sensation is when a patient is unable to open or keep open their eye.
3) Iritis is the same as anterior uveitis and the cardinal sign of this is ciliary flush (pictured above): a red ring around the iris (limbus).
4) Iritis requires urgent ophthalmologic consultation and can be caused by a number of processes:
- Infectious: syphilis, TB, toxoplasma, toxocara
- Inflammatory: reactive arthritis, IBD
- Infiltrative: sarcoidosis