A 35-year-old man presents with his third episode in two years of a painful, red, light-sensitive right eye. Each episode lasted 2–3 weeks and responded to eye drops from his ophthalmologist, but the episodes now alternate between eyes. Between attacks his vision is normal. On direct questioning he mentions chronic lower back stiffness every morning, easing after he starts moving, which he assumed was from his desk job. He has no skin rashes or joint swelling.
Examination Findings
Visual acuity: 6/12 right, 6/6 left. Right eye: ciliary flush (redness concentrated around the cornea), small irregular pupil with posterior synechiae (iris stuck to the lens) at 4 and 8 o’clock, and cells and flare in the anterior chamber (grade 2+). No hypopyon. Intraocular pressure: 10 mmHg right (low from ciliary shutdown), 14 mmHg left. Dilated fundus: no vitritis, no retinal lesions. He reports morning back stiffness lasting over an hour that improves with movement — present for two years.
Investigations
HLA-B27 testing (positive here); inflammatory markers (ESR/CRP); sacroiliac joint imaging given the back-stiffness history. Slit-lamp grading of cells and flare tracks treatment response. Syphilis and TB screening are considered per local protocol for uveitis workup.
Questions to Think About
- How does this presentation differ from the chronic uveitis seen in juvenile arthritis?
- Why are dilating drops as important as steroid drops in this attack?
- His eye drops work each time — why does he still need a rheumatologist?
Diagnosis
Recurrent acute anterior uveitis, HLA-B27 positive, with posterior synechiae — systemic spondyloarthritis workup indicated.
Reasoning
Reasoning: A painful, photophobic red eye with ciliary flush, anterior chamber cells and flare, and a small irregular pupil from posterior synechiae is acute anterior uveitis. The pattern — recurrent, unilateral but alternating between eyes, fibrinous enough to form synechiae — is textbook HLA-B27-associated disease. The morning back stiffness improving with movement is inflammatory back pain, the hallmark of ankylosing spondylitis/spondyloarthritis, which shares the HLA-B27 association. The eye is often the presenting feature of the systemic disease. Diagnosis: recurrent acute anterior uveitis, HLA-B27 positive, with posterior synechiae. Management: typical management of the acute attack is intensive topical steroids with a supervised taper plus cycloplegic/mydriatic drops — the dilating drops serve two purposes: pain relief from ciliary spasm and, crucially, keeping the pupil mobile to break and prevent posterior synechiae, which otherwise cause permanent pupil distortion and cataract risk. Intraocular pressure is monitored (steroids can raise it; inflammation can lower or later raise it). Beyond the eye: rheumatology referral for the spondyloarthritis — sacroiliac imaging and systemic assessment. Frequent recurrences may need systemic immunomodulatory therapy directed by rheumatology rather than repeated steroid courses alone. He is counselled to present within 24 hours of the next attack’s first symptoms, because early treatment prevents synechiae, and that his back symptoms deserve evaluation in their own right.
Differential Diagnosis
- Herpes simplex anterior uveitis — ruled out: no dendritic history, no iris atrophy or raised pressure pattern typical of herpetic disease; the recurrent unilateral alternating pattern with fibrin favours HLA-B27.
- Fuchs uveitis — ruled out: that is chronic, low-grade, with stellate keratic precipitates and heterochromia — the opposite of this acute painful fibrinous picture.
- Juvenile idiopathic arthritis uveitis — ruled out: that is chronic, painless, and white-eyed in children; this is acute and painful in an adult.
- Infectious endophthalmitis — ruled out: no surgery or trauma, no severe pain with hypopyon out of proportion, vision preserved.
Management
Urgent ophthalmology care: intensive topical steroids with taper plus cycloplegic/mydriatic drops to prevent synechiae; IOP monitoring; rheumatology referral for spondyloarthritis; long-term: systemic therapy per rheumatology for frequent recurrences.
Key Learning Points
- Acute anterior uveitis: painful red eye with photophobia, ciliary flush, small pupil, and cells/flare — the opposite of painless chronic uveitis.
- Posterior synechiae (iris stuck to lens) are the complication to prevent — dilating drops keep the pupil mobile during attacks.
- HLA-B27 anterior uveitis is typically unilateral, alternating, recurrent, and fibrinous — and linked to ankylosing spondylitis.
- Ask every uveitis patient about back pain and stiffness: the eye may be the first clue to systemic spondyloarthritis.
- Recurrent disease needs a rheumatology partnership — systemic immunomodulation may be required, not just eye drops.
Red Flags
- Hypopyon (layered pus in the anterior chamber) — severe inflammation; urgent specialist care.
- Raised pressure with inflammation — inflammatory glaucoma risk; do not miss.
- Posterior segment inflammation (vitritis, retinal lesions) — intermediate/posterior uveitis workup, different pathway.
- No improvement within days of intensive steroids — reconsider diagnosis and compliance.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.
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