A 67-year-old woman with a 10-year history of Crohn’s disease presented to eye casualty with complaints of blurred vision, pain and photophobia in her right eye. She denied any gastrointestinal symptoms of abdominal pain or diarrhoea. She had a history of episodic anterior uveitis on four previous occasions, which responded well each time to topical steroids. Uveitis was believed to be associated with Crohn’s disease and the patient remained compliant on azathioprine and mesalazine. The patient had never received treatment with monoclonal antibodies against tumour-necrosis factor alpha, such as infliximab.
Examination at presentation revealed best corrected visual acuity (BCVA) of 6/9 in the affected right eye (6/9 in the left eye). The patient’s pupils were equal and reactive to light and accommodation. Eye movements were full and complete and visual fields were normal. Colour vision was normal in both eyes (17/17 Ishihara plates bilaterally).
Examination of the dilated fundus revealed macular oedema in the affected eye with an optic disc of normal appearance.
A diagnosis of acute anterior uveitis with macular oedema associated with Crohn’s disease was made and the patient was started on topical dexamethasone 0.1% ophthalmic suspension hourly for 48 h then tapering over 4 weeks.
At review 2 weeks later, the patient reported a marked deterioration in her vision in the affected eye. Examination revealed worsening of her visual acuity to 6/18 and this was attributed to opacification of the posterior lens capsule in the pseudophakic eye, which received treatment in the form of YAG-laser capsulotomy.
However, soon afterwards, her visual acuity deteriorated further to 6/36 and a relative afferent pupillary defect was noted. Colour vision was also markedly diminished (1/17 Ishihara plates) in the affected eye.
Stereoscopic slit lamp examination of the dilated fundus revealed macular oedema with severe swelling of the optic disc ().
Fundus photograph. Notice the marked optic disc swelling with vascular congestion.
Despite a paucity of gastrointestinal symptoms, blood tests were requested. These revealed normal white cell count (6.7×109/L) and C-reactive protein levels (<5 mg/L).