A 28-year-old man comes to the physician because of a 2-day history of redness, pain, and blurred vision in his right eye. He also reports significant sensitivity to light. He has a history of intermittent low back pain and stiffness that is worse in the morning and improves with activity. Physical examination of the right eye shows circumcorneal injection (ciliary flush) and a constricted, irregular pupil. Slit-lamp examination reveals a flare and cells in the anterior chamber. The rest of the physical examination is notable for limited forward flexion of the lumbar spine and tenderness over the sacroiliac joints.
Which of the following is the most appropriate next step in the management of this patient’s ocular condition?
The correct answer is:
E) Topical prednisolone.
The patient is presenting with acute anterior uveitis (iritis), characterized by a painful red eye, photophobia, ciliary flush, and the presence of leukocytes and protein (cells and flare) in the anterior chamber. His history of inflammatory back pain and limited spinal mobility is highly suggestive of ankylosing spondylitis, an HLA-B27-associated spondyloarthropathy. Acute anterior uveitis is the most common extra-articular manifestation of these conditions. The primary treatment for non-infectious anterior uveitis is topical corticosteroids such as topical prednisolone to reduce ocular inflammation and prevent complications like vision loss.
Answer choice A: Atropine drops, is incorrect. Atropine is a cycloplegic agent used in the management of uveitis to dilate the pupil, prevent the formation of synechiae (adhesions), and relieve pain caused by ciliary muscle spasm. While it is an important adjunctive therapy, topical corticosteroids are the definitive next step to treat the underlying inflammatory process.
Answer choice B: Intravenous acyclovir, is incorrect. Intravenous or oral acyclovir is used for viral uveitis or keratitis, often caused by herpes simplex virus (HSV) or varicella-zoster virus (VZV). Viral etiology is usually suggested by the presence of vesicular skin lesions or dendritic corneal ulcers, whereas this patient's systemic symptoms point toward an autoimmune/inflammatory cause.
Answer choice C: Intravenous methylprednisolone, is incorrect. Systemic high-dose corticosteroids are reserved for severe, sight-threatening ocular inflammation, such as optic neuritis or severe posterior uveitis. Uncomplicated acute anterior uveitis is typically managed with topical therapy rather than systemic intervention.
Answer choice D: Topical ciprofloxacin, is incorrect. Topical antibiotics are indicated for bacterial conjunctivitis or bacterial keratitis. Bacterial conjunctivitis typically presents with purulent discharge and lacks the deep-seated pain, photophobia, and anterior chamber findings seen in this patient.
Key Learning Point
Acute anterior uveitis (iritis) presents with a painful red eye, photophobia, and "cells and flare" on slit-lamp examination. It is strongly associated with HLA-B27-positive conditions like ankylosing spondylitis and reactive arthritis. Management involves topical corticosteroids to reduce inflammation and topical cycloplegics to prevent synechiae and manage pain.
