Ophthalmology Consult Note

Subjective

• Chief Complaint: Painful red right eye and photophobia x 2 days.
• History of Present Illness: 64yo M inpatient on Gen Surg ward (POD 4 laparoscopic anterior resection for diverticulitis). Developed acute-onset deep aching pain OD, tearing, and blurred vision starting 18/05/2026. Denies trauma, purulent discharge, or prior similar episodes.
• Past Ocular History: Bilateral nuclear sclerotic cataracts (unoperated). Presbyopia.
• Medical History: Diverticulitis, ankylosing spondylitis (HLA-B27 positive), HTN.
• Medication History: amlodipine 5 mg PO daily, paracetamol (acetaminophen, Tylenol®) 1,000 mg PO QID PRN, enoxaparin (Lovenox®) 40 mg SC daily.
• Allergies: Penicillin (urticaria).
• Family Ocular History: Mother with primary open-angle glaucoma.
• Social History: Ex-smoker (quit 10 yrs ago, 20 pack-year hx). Social EtOH. Retired accountant.

Objective

• Visual Acuity: OD: 20/60 uncorrected, 20/40 pinhole; OS: 20/25 uncorrected, 20/20 pinhole.
• Intraocular Pressure: Tonopen: OD 14 mmHg, OS 16 mmHg at 14:15.
• Anterior Segment:
  • Lids/Lashes: WNL OU.
  • Conjunctiva/Sclera: 2+ circumcorneal ciliary flush OD; white and quiet OS.
  • Cornea: Fine non-granulomatous keratic precipitates inferiorly OD; clear OS.
  • Anterior Chamber: 2+ cells and 1+ flare OD; deep and quiet OS. No hypopyon.
  • Iris: Posterior synechiae at 5 o'clock OD; normal architecture OS.
  • Lens: 1+ nuclear sclerosis OU.
• Posterior Segment:
  • Vitreous: Clear, no anterior vitreous cells OU.
  • Disc: Pink, sharp margins, C/D 0.3 OU.
  • Macula: Flat, intact foveal reflex OU.
  • Vessels/Periphery: Normal calibre, retina flat and attached 360 degrees OU.
• Additional Tests: Fluorescein staining: negative for epithelial defects or dendrites OU.

Assessment

• Acute anterior uveitis, right eye (H20.011).
• Differential diagnosis: HLA-B27-associated iridocyclitis vs. endogenous endophthalmitis (low suspicion given clear vitreous and absence of systemic sepsis) vs. viral keratouveitis.

Plan

• Treatments:
  • prednisolone acetate (Pred Forte®) 1 % ophthalmic suspension 1 drop OD q1h while awake for 3 days, then taper to q2h.
  • cyclopentolate (Cyclogyl®) 1 % ophthalmic solution 1 drop OD TID to break synechiae and relieve ciliary spasm.
• Follow-Up: Review in outpatient ophthalmology clinic in 4 days (or inpatient review if still admitted). Return immediately for worsening pain, decreased vision, or increased redness.
• Patient Education: Discussed etiology of acute iritis linked to underlying ankylosing spondylitis, strict adherence to steroid drop regimen, need for slow taper, and red-flag symptoms.
• Referrals: Outpatient Rheumatology follow-up recommended post-discharge for systemic disease reassessment.