Ophthalmology
Question 89 of 97
A 54 year old man presents to the Emergency Department with a 7 hour history of left eye irritation and watering. He has no significant past medical history. On examination you note sectoral redness. What is the most likely diagnosis?
Answer:
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)
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)
- Symptoms
- 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
- Symptoms
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 |
