cell and flare

The patient is a 26 y.o. female who presents for right eye pain.  She reports that yesterday she was playing basketball and was poked in the eye by another player’s finger.  That evening she took a pain pill, Vicodin 5-325 mg, and went to sleep.  This morning she noted increased pain and swelling around the eye, along with redness of the eye and some “red stuff” on her finger when she wiped the eye with her hand.  She endorses HA, sensitivity to light and increased pain with eye movement.  She denies subjective fever, chills, neck pain/stiffness, N/V.

Eye Exam 
PERRLA, EOMI, left eye 20/20, right eye 20/30, right eye – conjunctival injection and 0.5 cm diameter flat red lesion in RLQ of eye
Slit lamp exam – right eye – direct and consensual photophobia, circumlimbal flush, mild hazy opacity of cornea but no cell and flare, asymmetry of pupil

Simple corneal abrasion vs iritis

Final dx:  traumatic irits + small corneal abrasion

Teaching points:

1.         When you call ophthalmology, you must know what you’re talking about! Giving ophthalmology an incomplete or poorly informed exam is the equivalent of calling cardiology and telling them that the EKG looks like some squiggles that are going up and down and back and forth!

2.         The exam begins with visual acuity and fluorescein staining. For things other than simple corneal abrasions, a slit-lamp exam is indicated.

3.         If you’re not overwhelmed during your shift, go into the room with ophthalmology and have them explain what it is that they’re seeing in the exam.

4.         When you practice in the real world you will not have ophthalmology at your fingertips. Quite frequently you will have to call ophthalmology and give them a very clear story and exam and they will frequently have you initiate treatment and they will see the patient the next day.

5.         Iritis, also called anterior uveitis, is a serious problem that you need to be able to recognize. The hallmark signs and symptoms are direct and consensual photophobia, circumlimbal flush, and cell and flare in the anterior chamber. See the video below to see how to look at cell and flare more clearly.

6.        Complication of uveitis can be an anterior or posterior synechia. This is an adherence of the iris to the lens or the cornea. It causes cosmetically disturbing changes in the shape of the pupil. The acute treatment for iritis is the use of dilating agents like homatropine and topical steroids. It is very reasonable to start steroids for this condition if you do it in conjunction with ophthalmology and you don’t see any evidence of a herpetic or zoster lesions.

Awesome video on how to do the exam for cell and flare