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Why does this man have a watery, red eye?

This 29-year-old man had a painful, watery eye that had not responded to chloramphenicol drops. Dr Mike Wyndham describes the case

 

The patient

This 29-year-old man had just joined the practice. He presented with a red eye that had developed three days earlier. The eye felt uncomfortable and had been watering a great deal. He felt that his vision wasn't quite as good as normal. He had attended A&E two days previously and had been prescribed chloramphenicol eye drops. This had made no impact on the condition. Examination revealed no discharge or any staining with fluorescein. There was no localised lymphadenopathy.

First instinct

The lack of any purulent discharge in the history made the diagnosis of a bacterial conjunctivitis unlikely. As the eye may be an indicator for systemic disease, it was important to have a full medical history. The patient denied having any general problems.

Differential diagnosis

• Conjunctivitis – viral and allergic

• Herpes simplex

• Anterior uveitis

• Corneal abrasion

• Episcleritis

Adenovirus is the most common cause of viral conjunctivitis. It is likely that both eyes would be affected and accompanied by upper respiratory symptoms. The virus causes the pre-auricular lymph glands to enlarge and there was an absence of lymphadenopathy in this case.

Allergy is virtually always associated with itching and the eye is no exception. The patient said his condition was uncomfortable but didn't mention itch, so allergy seemed unlikely.

A dendritic ulcer is the most common presentation of herpes simplex affecting the eye. This should certainly stain with fluorescein if present – but there was no staining on this occasion.

Uveitis would certainly fit with the symptoms and its unilateral nature would be consistent with the diagnosis. The condition may be associated with systemic disease such as ankylosing spondylitis but in 50% of cases there is no associated problem.

Corneal abrasions are caused by injury. This may be from wearing contact lenses or another external cause, such as a foreign body entering the eye. There was no history of this.

Episcleritis tends to cause a localised patch of redness and the eye certainly did not have this appearance.

The hidden clue

Having decided that this might be a uveitis, I asked him about his general health and found out he had been suffering from recurrent abdominal pain and intermittent diarrhoea for some months. His previous GP suggested that it was probably irritable bowel syndrome. With the development of his eye problem, I wondered if this might be Crohn's disease.

Getting on the right track

I referred him immediately to our local eye clinic and a diagnosis of anterior uveitis was confirmed. This was treated with steroid eye drops. The bowel symptoms were later confirmed as Crohn's disease.

Dr Mike Wyndham is a GP in Edgware, north London

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