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• W4387232246 abstract "Figure: eye pain, redness, symptoms, rheumatoid arthritis, tearing, vision loss, blurring, flashers, floaters, fevers, chills, discharge, afebrile, OD, visual acuity, photophobia, erythema nodosum, violet, erythema, vessels, diagnosis, anterior scleritis, sclera tissue, conjunctiva, choroid, sclera, oral corticosteroidsFigureFigureA 28-year-old woman with a history of juvenile rheumatoid arthritis presented with worsening left eye pain and redness with associated tearing. She had no vision loss, blurred vision, diplopia, flashers, or floaters. She also had no fevers, chills, or discharge, and she didn't use contact lenses or have any recent surgery or eye trauma. She last took disease-modifying antirheumatic drugs in 2018. She was afebrile, and her vital signs were within normal limits. Her visual acuity was OD 20/25, which corrected to 20/20 with pinholes; OS 20/50, which corrected to 20/30 with pinholes; and OU 20/20. Her visual fields were fully intact. Her pupils were mid-range, equal, round, and reactive to light without direct or consensual photophobia. Ocular movements were intact, although she said they were painful. Intraocular pressure was 16 mm Hg. A fluorescein exam did not demonstrate any abrasions or ulcerations. A slit lamp exam showed no cell and flare. Her exam was most notable for erythema nodosum with an underlying bluish violet tinge to the temporal aspect of her left eye surrounded by few overlapping, prominent vessels. The vessels and erythema remained fixed in position when gentle pressure was applied with a damp cotton-tipped applicator. What is the diagnosis? Find a case discussion on the next page. Diagnosis: Anterior Scleritis Scleritis is an uncommon but potentially vision-threatening inflammatory process. It involves the sclera tissue, located between the conjunctiva and the choroid. More than half of scleritis cases are associated with systemic vasculitis or autoimmune conditions, although infectious and traumatic causes occur. Scleritis can involve the anterior sclera or posterior sclera, and includes the diffuse, nodular, and necrotizing scleritis subtypes. Left untreated, scleritis can be complicated by marginal corneal ulcers, interstitial keratitis, anterior uveitis, vitritis, macular edema, and retinal detachment. (Am J Ophthalmol. 2000;130[4]:469.) Patients typically present with constant, severe eye pain that worsens with ocular movement. Patients might also report tearing, eye redness, photophobia, or visual changes depending on the location of involved tissue. A systematic approach to examining the red and painful eye is crucial. (EMN. 43[8]:32; https://bit.ly/3qyJ7Tl.) Anterior scleritis presents as a violet discoloration of the sclera, often with enlarged, crisscrossed vessels underlying it. Posterior scleritis lacks these external visible findings and is more difficult to detect on external exam, but fundoscopic exam may reveal macular edema or posterior chamber inflammatory changes. (Asia Pac J Ophthalmol. 2020;10[2]:212; https://bit.ly/3KOBvTF.) Scleritis can sometimes be confused with episcleritis, which is superficial inflammation and often more benign. Episcleritis typically causes minimal to mild pain, no vision changes, and mobile vessels that blanch with topical phenylephrine. It is common to do laboratory testing, including inflammatory markers and infectious disease testing such as syphilis screening, but routine imaging and laboratory testing is not required to diagnose scleritis. All patients with scleritis should undergo further diagnostic testing, however, to identify underlying triggers or associated systemic disorders, typically guided by a rheumatologist during admission or close follow-up. Scleritis treatment should be initiated in the ED to prevent vision loss, and urgent consultation with ophthalmology is required. Treatment requires systemic medications—primarily oral corticosteroids as the first line of treatment—which is an important distinction from the treatment of episcleritis that typically responds to topical agents. (Am J Ophthalmol. 2000;130[4]:469.) Ophthalmology generally considers the disease severity and type of scleritis when selecting the appropriate agents, which include indomethacin, prednisone, and other glucocorticoids. Immunosuppressants such as methotrexate, mycophenolate mofetil, and azathioprine are sometimes used for refractory cases or to prevent recurrence. (Asia Pac J Ophthalmol. 2020;10[2]:212; https://bit.ly/3KOBvTF.) The duration of treatment will depend on clinical response, and close specialist follow-up is crucial to monitor for improvement after discharge or admission. Oral analgesics should also be considered. This patient had relatively early involvement with no visual changes, and she was discharged from the ED directly to the ophthalmology clinic for outpatient management. She was started on 60 mg of PO prednisone daily for the first week. Her symptoms were improving, her vision remained intact, and she began a prednisone taper a week later. She planned to reestablish care with rheumatology promptly. DR. TRILLES is a second-year emergency medicine resident at Los Angeles General Medical Center. DR. BURKHOLDER is an assistant professor of clinical emergency medicine at the Keck School of Medicine at the University of Southern California. Follow him on Twitter @tayburkholder. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]." @default.
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• W4387232246 title "Symptoms: Left Eye Pain, Redness" @default.
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