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71

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Ophthalmology

Question 117 of 300

A 64 year old woman presents to the Emergency Department in the middle of the night complaining of a painful right eye. She has a past medical history of rheumatoid arthritis. She describes a "boring" pain that is worse on movement. On examination you note reduced visual acuity, pain on ocular palpation and a bluish discolouration of the sclera. What is the most likely diagnosis?

Answer:

Scleritis:
  • Symptoms
    • Acute onset of severe ocular pain and redness (pain may be described as 'deep' or 'boring' and is worse with ocular movement and at night)
    • Tender eye
    • Lacrimation
    • Photophobia
    • Visual disturbance
  • Signs
    • Deep scleral vessel engorgement
    • Bluish purple discolouration of the sclera
    • Pain on ocular palpation
    • Reduced visual acuity

Episcleritis and Scleritis

Ophthalmology

Last Updated: 12th February 2021

Episcleritis is inflammation of the episclera (a thin layer of tissue that lies between the conjunctiva and the sclera).

Scleritis is inflammation of the sclera (the white outer wall of the eye).

Risk factors

  • Episcleritis:
    • Most patients do not have an underlying systemic inflammatory or infectious disease
  • Scleritis:
    • Most patients have an underlying systemic inflammatory or infectious disease (the most common association is with rheumatoid arthritis)

Clinical features

  • Episcleritis:
    • Symptoms
      • Acute onset of redness, irritation and watering of the eye
    • Signs
      • Sectoral redness in eye (inflammatory nodule may be present over the area)
      • Episcleritis may be differentiated from scleritis by using phenylephrine eye drops, which cause blanching of the blood vessels in episcleritis, but not in scleritis (also episcleral vessels can be moved with a cotton bud)
  • Scleritis:
    • Symptoms
      • Acute onset of severe ocular pain and redness (pain may be described as 'deep' or 'boring' and is worse with ocular movement and at night)
      • Tender eye
      • Lacrimation
      • Photophobia
      • Visual disturbance
    • Signs
      • Deep scleral vessel engorgement
      • Bluish purple discolouration of the sclera
      • Pain on ocular palpation
      • Reduced visual acuity

Management

  • Episcleritis
    • Referral to ophthalmology to confirm diagnosis
    • For patients not bothered by the presence of episcleritis, treatment is generally not needed because symptoms and findings typically resolve over several weeks
    • For patients bothered by the presence of episcleritis (in order of use):
      • Artificial tear preparations
      • Topical NSAIDs
      • Topical glucocorticoids
  • Scleritis
    • Urgent referral to ophthalmology
    • Systemic therapy with NSAIDs, glucocorticoids or other immunosuppressive drugs

Complications

  • Episcleritis
    • Rare
  • Scleritis:
    • Keratitis
    • Scleral thinning
    • Raised intraocular pressure
    • Globe perforation
    • Glaucoma
    • Cataracts
    • Retinal detachment
    • Permanent visual loss

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l
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