Can't see, can't read, can't be bored - Review

Serena Williams strolls into your ED complaining of right eye pain for 2 days. She tells you that her right eye started hurting 2 day ago, after a tennis ball hit her face while practicing to dominate the US Open and win the 2015 Serena Slam. Since then she developed pain, photophobia, and redness. She denies any foreign body sensation.

On exam, you note mildly decreased visual acuity of the affected eye, conjunctival injection with perilimbal flush (most redness around the iris), consensual photophobia (light shined in the left eye also hurts the right), and a miotic, poorly reactive pupil.

Visual fields and extra-ocular muscles intact, no soft-tissue swelling, normal ocular pressures, and no corneal abrasion or foreign body on Fluorescein slit-lamp exam.

What's the diagnosis?

Iritis, or anterior uveitis, specifically traumatic iritis in this case. Pain is caused by irritation of the ciliary muscles and nerves, which causes the miotic pupil and photophobia. On slit lamp, you may also see “flare and cells.” Flare refers to the haziness/fogginess seen in the anterior chamber from transudate, and cells are WBCs foating in the anterior chamber, which look like snowflakes. A video is worth a thousand words so check this out. This is NOT conjunctivitis as there is decreased visual acuity and photophobia.

Treatment?

This is urgent, but not a true ocular emergency. Patients should see an ophthalmologist in 24-48 hours. Treatment is aimed at reducing inflammation (corticosteroid eye drops) and reducing pain (cycloplegic drops to relax the ciliary muscles, like homotriptine).

What else causes uveitis?

Inflammatory / Autoimmune: HLA-B27 types including ankylosing spondylitis, reactive arthritis/Reiter syndrome (arthritis, uveitis, and urethritis — or, can’t see, can’t pee, can’t climb a tree!), and IBD. Also sarcoidosis, MS, and Behçet syndrome

Infectious disease: HSV, zoster, TB, syphilis, Lyme disease, toxoplasmosis

Malignancy/neoplasms: lymphoma, melanoma, leukemia

What is a Serena Slam?!?!!

Serena has won all five recent Grand Slam tournaments: The Australian Open, the French Open, Wimbledon, and 2014 US Open. If she wins the 2015 US Open, she will be a ‘Calendar Grand Slam’ champion, which was last done in 1988. Go Serena.

References

Tintinalli’s 7th Ed. Ch 236

http://lifeinthefastlane.com/uveitis/

http://www.rootatlas.com/wordpress/video/561/cell-and-flare-in-the-eye-video/

By Doc Birnbaum

Special Thanks to Docs Goldstein and Willis

Disclaimer: This is a made-up case and Serena Williams was never a patient at Janus General or Kings County. Also, she is way too good of a player to get hit in the face with a ball. So this is obviously fictional.

2015 US Open starts 8/31 in Brooklyn’s backyard (Queens).