Ophthalmology KFP 1.2 – Betty has a sore blue eye

by | Jan 11, 2018

Betty is a 50 year old woman with a history of Rheumatoid Arthritis and Osteoporosis who presents with severely painful and red eye which describes as having a “blue tinge”. The pain is described as “boring” and radiates to her head and neck. Her eye is very tender to touch. She has a watery discharge, no change in her vision. She is on Aledronate 70mg weekly for osteoporosis.

What is your primary dagnosis? (1)

  1. Scleritis

What are the differentials of anterior scleritis? (5)

  1. Uveitis or iritis
  2. Keratitis or corneal ulcerations
  3. Conjunctivitis
  4. Acute-angle closure glaucoma

What are the key features of history in scleritis? (6)

  1. Deeply diffusley Red Eye
  2. Violaceous hue
  3. Severe eye pain
  4. Eye tender to palpation
  5. VA decreased with advancing disease
  6. Watery Discharge
  7. Diplopia in posterior disease
  8. Fever
  9. Vomiting
  10. Headache

What are the key features of history in posterior scleritis? (5)

  1. Severe eye pain + Quiet white eye
  2. Decreaed VA in the absence of pain
  3. Lid oedema.
  4. Proptosis.
  5. Optic disc swelling.
  6. Retinal detachment symptoms

What are the key features of examination in scleritis?

  1. Deeply diffusley Red Eye
  2. Violaceous hue
  3. Eye tender to palpation
  4. VA decreased with advancing disease
  5. Watery Discharge
  6. Diplopia in posterior disease
  7. Nil blanching with 10% phenylephrine
  8. Fever

How do you differentiate episcleritis from scleritis? (3)

  1. Episcleritis is usually localised wedge of redness, usually laterally
  2. Instill phenylephrine eye drops and see if it blanches as in episcleritis
  3. Violaceous colour in scleritis
  4. Can manipulate nodular episcleritis with cotton tip but fixed in scleritis

What are the most common categories of diseases are associated with scleritis? (2)

  1. Connective tissue disease
    Infections

What connective tissue diseases are most commonly associated with scleritis? (5)

Disease can be isolated to the eye, but in up to half of affected individuals it occurs in the context of an immune-mediated systemic inflammatory condition:

  1. Rheumatoid arthritis
  2. Wegener’s granulomatosis
  3. Relapsing polychondritis
  4. Systemic lupus erythematosus
  5. Reactive arthritis
  6. Polyarteritis nodosa
  7. Ankylosing spondylitis.

What microbiologial pathogens are causing local infection of the cornea are most commonly associated with this condition? (4)

  1. Pseudomonas aeruginosa,
  2. Streptococcus pneumoniae,
  3. Staphylococcus aureus and
  4. Varicella-zoster virus.

You perform routine serology of FBC, LFT, UEC. What are the next important steps in serological investigation? (5)

  1. ESR
  2. CRP
  3. Antinuclear antibody
  4. Rheumatoid factor
  5. Anti-CCP

What is the most important immediate first step in the management of scleritis? (1)

  1. Emergent ophthalmology referral

What are the complications of scleritis? (5)

  1. Vision loss
  2. Raised intraocular pressure
  3. Retinal detachment
  4. Uveitis
  5. Cataract.
  6. Posterior scleritis can lead to rapid permanent visual loss

References

  1. patient.info
  2. Murtaghs
  3. Colour Atlas of Family Medicine
  4. Dynamed