What is the best course of action for a patient with a history of ulcerative colitis, autoimmune hepatitis, and uveitis, presenting with acute right eye redness and soreness, while currently taking Pentasa (mesalamine), thioguanine, and vitamin D?

Urgent Ophthalmology Referral for Suspected Uveitis Recurrence

This patient requires same-day ophthalmology evaluation for suspected uveitis recurrence, given the history of bilateral uveitis and current right eye redness with soreness. While the presentation appears mild, the patient's history of severe left eye uveitis requiring steroid treatment and ongoing immunosuppression with thioguanine creates significant risk for vision-threatening complications if uveitis is not promptly diagnosed and treated 1.

Immediate Management Steps

Ophthalmology Referral (Same Day)

• Arrange urgent ophthalmology assessment within 24 hours to perform slit-lamp examination, measure intraocular pressure, and assess for anterior chamber inflammation that cannot be detected on basic examination 1
• The temporal redness and vessel prominence, while subtle, may represent early anterior uveitis in this high-risk patient 1
• Do not initiate topical corticosteroids before ophthalmology evaluation, as this may mask findings and delay appropriate diagnosis 1

Why This Cannot Wait

• Patients with inflammatory bowel disease and autoimmune hepatitis have significantly elevated risk of recurrent uveitis, particularly when on immunosuppressive therapy like thioguanine 1
• The patient's previous left eye uveitis was severe enough to cause multiple days of insomnia, indicating aggressive inflammatory disease 1
• Any patient with a history of uveitis presenting with new eye redness requires ophthalmology evaluation to rule out recurrence, even if symptoms seem mild 1

Differential Diagnosis Considerations

Most Likely: Anterior Uveitis Recurrence

• History of bilateral uveitis (left eye previously, now right eye symptoms) in setting of ulcerative colitis and autoimmune hepatitis 1
• Temporal injection pattern can represent early anterior segment inflammation 1

Alternative Diagnoses to Exclude

• Simple episcleritis: Would typically present with less soreness and no history of severe uveitis 2
• Conjunctivitis: Less likely given lack of discharge and patient's inflammatory disease history 1
• Scleritis: Would present with severe, boring pain rather than mild soreness, but must be excluded 1, 2

Treatment Approach Based on Ophthalmology Findings

If Anterior Uveitis Confirmed

• Topical corticosteroids (prednisolone acetate 1% or equivalent) are first-line treatment, typically started at frequent dosing (every 1-2 hours while awake) then tapered based on response 1
• Continue current systemic immunosuppression with thioguanine, as this provides background control of inflammatory disease 1
• Consider need for systemic corticosteroids if inflammation is severe or posterior segment involvement is present 1

If Posterior Uveitis or Severe Inflammation

• Systemic immunosuppression intensification may be required, potentially adding systemic corticosteroids or considering biologic therapy (infliximab, adalimumab, or vedolizumab) 1
• Thioguanine alone may be insufficient for sight-threatening uveitis - the patient may require combination therapy 1

Critical Monitoring Parameters

Short-Term (During Acute Episode)

• Intraocular pressure monitoring is essential, as both uveitis and topical corticosteroid treatment can cause elevated pressure and glaucoma 1
• The patient already has planned glaucoma monitoring, indicating previous pressure concerns 1
• Visual acuity assessment at each visit to detect any deterioration 1

Long-Term Considerations

• Any patient with inflammatory bowel disease and uveitis affecting the posterior segment should be on systemic immunosuppression such as azathioprine, biologics, or other agents 1
• Current thioguanine therapy (20mg daily) provides some immunosuppression but may need optimization if recurrent uveitis develops 1, 3

Common Pitfalls to Avoid

Do Not Delay Ophthalmology Referral

• The single most important error would be treating this as simple conjunctivitis or episcleritis without specialist evaluation 1, 2
• Even mild-appearing eye redness in patients with inflammatory bowel disease and previous uveitis warrants urgent assessment 1

Do Not Start Topical Steroids Empirically

• While topical corticosteroids are appropriate for confirmed anterior uveitis, starting them before proper diagnosis can mask findings and delay recognition of more serious conditions 1
• Prolonged or inappropriate topical corticosteroid use risks elevated intraocular pressure, cataract formation, and infectious complications 1

Do Not Ignore Systemic Disease Activity

• Uveitis recurrence may indicate inadequate control of underlying inflammatory bowel disease or autoimmune hepatitis 1, 2
• Review adherence to Pentasa (mesalamine) and thioguanine, and consider whether systemic disease optimization is needed 4

Coordination with Gastroenterology

Assess Ulcerative Colitis Control

• The patient is on Pentasa 4g daily and thioguanine 20mg daily for ulcerative colitis maintenance 4
• Uveitis activity often parallels inflammatory bowel disease activity, so ensure colitis is well-controlled 1
• Recent blood tests showed no inflammation (normal CRP), suggesting reasonable systemic control 4

Consider Treatment Escalation if Needed

• If recurrent uveitis develops despite current therapy, biologic agents (infliximab, adalimumab, vedolizumab) may be indicated for both ulcerative colitis and uveitis control 1, 4
• These agents can address both conditions simultaneously and may be superior to thioguanine monotherapy for patients with extraintestinal manifestations 1