BMJ 2010: 341: 787 – 840 (16th October)

If I ever get round to doing those patient satisfaction surveys I’m meant to be doing for my appraisal, then it seems I should be focusing on the proportion of patients who were less than totally satisfied, rather than the average score. And, alas, while a low score can indicate a problem, I don’t get to assume that a high score means that I must be doing brilliantly. Low scores were good indicators of problems, but patients could give high scores to care that was merely adequate (ah, the great British public).

Concerns that Omeprazole might interfere with the action of Clopidogrel can now be laid to rest: the interaction was found not to be clinically meaningful.

When looking for physical causes of easy bleeding in a child, discuss with a paediatric haematologist (or adult haematologist with a special interest in homeostasis) before doing the blood tests, to make sure all the necessary ones get done. Oh, and did you know that 30% of cases of haemophilia are new genetic mutations? If haemophilia is suspected, don’t rule it out on the lack of a family history.

And a review article on uveitis. For starters, what it actually is, for people like me who are trying to remember which bit the uvea is. It is a collective term for the iris, ciliary body, and choroid. The choroid is the layer of the eyeball between the sclera on the outside and the retina on the inside. OK, here’s where the ability to draw a picture would be helpful… Picture those schemata of the anatomy of the eye, with the circle and then the curved shape on the front for the cornea. The front part of the circle-shape forms the iris, with the ciliary body where the iris joins the rest of the eyeball. So, the iris, ciliary body, and choroid form the circular shape of the eyeball, with the sclera around the outside of the choroid and the retina lining the inside. Clear as mud?

Anyway, that circle of iris, ciliary body, and choroid is the uvea. As you can imagine, inflammation of it is often associated with inflammation of other bits of the eye such as the retina (uveoretinitis or retinal vasculitis), the vitreous (vitritis), or the optic nerve (papillitis). Terms that have been dropped from this mind-cluttering collection are iritis (take a guess) and iridocyclitis (inflammation of the iris + ciliary body). Both of these are now referred to as anterior uveitis, a term I can never use without the Monty Python crew drawing it out into a long chord in the back of my mind. Well, there you have it – ‘iritis and iridocyclitis’ just wouldn’t have scanned properly in that song.

How does it present? Acute anterior uveitis presents with painful red eye, photophobia, and blurred vision. None of these symptoms is specific, but, since it seems fair to say that they’re the kind of symptoms you should take seriously regardless of the precise itis that happens to be causing them, I’ll let the ophthalmologists worry about that one. Sticky/mucoid discharge is not found in uveitis, so that would suggest a diagnosis of conjunctivitis. Examination may show circumcorneal redness (i.e. worst around the edges of the eye), and a small or irregular pupil. (The small size is due to spasm in the iris sphincter, and the irregularity due to distortion from adherence of the iris to the lens.)

As for posterior uveitis, it may be painless, may be bilateral, and may not cause redness. What it can cause is loss of vision. Floaters may indicate inflammation of the vitreous. And, of course, there are those nasty insidious chronic types of uveitis – such as uveitis in juvenile idiopathic arthritis – which may not cause any symptoms at all.

There are a plethora of causes – herpes/varicella viruses, TB, syphilis, various auto-immune diseases, and lymphoma. Course may be acute, recurrent, or chronic. Treatment mainly seems to revolve around steroids in their various formats. And that, since I’m a GP and not an ophthalmologist, is probably about as much as I need to know.

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About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in BMJ, BMJ 2010, BMJ 341, Eyes, Medication. Bookmark the permalink.

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