45-year-old with rheumatoid arthritis and 3 days of throbbing eye pain and redness
What is your diagnosis?
The diagnosis is...
The image is consistent with a diagnosis of scleritis:
- Scleritis results from inflammation of the sclera. It can be idiopathic or related to underlying systemic disease such as autoimmune disease, infections, or trauma.
- Symptoms of scleritis include a severe, boring pain that can radiate to nearby facial structures. Redness, tearing, and photophobia may also be seen.
- Scleritis can be divided into anterior and posterior scleritis, depending on the area of involvement.
- Anterior scleritis is more common. It can be further subclassified as diffuse, nodular, or necrotizing scleritis.
What is the role of the primary care or emergency medicine physician?
- Refer to ophthalmology urgently!
- Perform a thorough physical exam to screen for concurrent autoimmune disease. Include examination of the joints, skin, heart, and lungs.
- Initiate a systemic workup to rule out underlying autoimmune disease:
- complete blood count, basic metabolic panel, erythrocyte sedimentation rate, and C-reactive protein
- serum antibody screen
- Initiate further testing if another etiology is suspected (ie, syphilis serologies, sarcoidosis screen).
What is the role of the ophthalmologist?
- Use the slit-lamp biomicroscope to examine the sclera, cornea, and anterior chamber. Findings include inflamed scleral vessels (cannot be moved with a cotton swab), edema, and a violaceous scleral hue.
- Perform a dilated fundus examination to rule out posterior involvement. Consider B-scan ultrasonography or fluorescein angiography if posterior scleritis is suspected.
What is the treatment?
Treatment of scleritis depends on the underlying etiology.
Treatment options include oral nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids. Topical therapy is typically unhelpful but may be indicated in specific cases.
Oral immunosuppressants can also be used if the condition is severe. High-dose immunosuppressants are first-line therapy for necrotizing scleritis.
Learn more: Ophthalmology resources for medical students