Primary iridocyclitis, right eye

H20.011

Clinical Vignette:

Patient Profile:

* Age: 27 years old

* Sex: Male

* Name: Charlie

History of Present Illness:

Charlie, a promising photographer with a knack for capturing the beauty of nocturnal urban life, had lately been noticing that his vision was not as crisp as it used to be. In particular, he found his right eye had become extremely sensitive to light, making his night-time shoots challenging. Along with the photosensitivity, he also noticed some redness and blurred vision in the same eye. Initially, he attributed these symptoms to his excessive screen time and unusual sleep patterns.

However, when the eye pain started, it was accompanied by a severe, throbbing headache on the same side, which was impossible to ignore. His right eye also started tearing up, and there was a noticeable decrease in visual acuity. Alarmed by the severity of his symptoms, Charlie decided to see an ophthalmologist.

Physical Examination:

Upon examination, the ophthalmologist noted that Charlie's right eye was indeed inflamed, and the iris of his right eye had a slightly irregular shape. There was also an increase in intraocular pressure.

Investigations and Diagnosis:

After conducting a slit-lamp examination, which confirmed inflammation in the iris and ciliary body of the right eye, Charlie was diagnosed with Primary Iridocyclitis in the right eye. This autoimmune condition, often linked to diseases like rheumatoid arthritis or sarcoidosis, was causing his eye discomfort and affecting his vision.

Immediate treatment with anti-inflammatory and cycloplegic drops was started to reduce the inflammation and alleviate the pain. Charlie was also referred to a rheumatologist to rule out any associated systemic conditions.

Diagnosis and ICD-10-CM Code:

Primary Iridocyclitis, Right Eye (H20.011)