Introduction
Learning Objectives:
·
To review the pathophysiology, classification
and features of scleritis
·
To review systemic disease associations of
scleritis
·
To review the diagnosis and management of
scleritis
Time Credit:
2 Hours
Case
A 58 year old male presents to the eye clinic with a 3 week history of a painful left eye. He says that his left eye has been constantly red the last few weeks and has had an increasingly “dull” pain in and around the eye. He feels it is worse at night and has had difficulty sleeping, and even during the day, the pain is extremely bothersome. He notes significant impairments in his work performance and has become increasingly reclusive because of the pain. He has taken Tylenol with little relief.
The patient notes no decreased vision or other visual symptoms from the eye. The pain occasionally feels “behind the eye” but he has otherwise had no headache. He has had no other general symptoms such as fever or cold symptoms. Past medical history is significant for only chronic lower back pain and stiffness he has had since a teenager but never seen a doctor for. He is on no regular medications.
On exam visual acuity is 6/6 and 6/7.5 in the right and left eyes, respectively. Pressures are 12 in the right eye and 16 in the left eye. Anterior segment exam is remarkable for the external redness shown below. The involved vessels are non-mobile when a cotton-tip applicator is applied. Fundoscopy is difficult secondary to photophobia, but appears to be normal.
What is the most likely diagnosis?
• Iritis
INCORRECT although iritis may produce a red painful eye with photophobia (and this patient may indeed have an element of iritis), the underlying cause of the patient’s symptoms is not a primary iritis.
• Episcleritis
INCORRECT although there may be an element of episcleritis present, it does not account for the patient’s clinical picture, especially of pain and non-mobile vessels.
• Scleritis
CORRECT
• Conjunctivitis
INCORRECT conjunctivitis can cause a red eye, although the clinical picture (e.g. severe pain, involvement of deeper vessels) suggests an alternative diagnosis.
Scleritis is an important cause of a painful red eye. It is often associated with systemic abnormalities, and commonly affects middle-aged Caucasion patients with a mean age at onset of 49 years.1 It is more common in females than males (approximately 2:1).1 2