How do you treat this red eye?

Notables on H + P:

• severe pain, can't sleep, insidious onset over past several days


• history of rheumatoid arthritis


• visual acuity 30/20


• no lid edema or ocular discharge


• globe tender to palpation


• PERRL, no afferent pupillary defect


• no floroscien uptake


• blood vessels don't move with pressure applied from Q-tip


• blood vessels don't blanch with application of topical phenylephrine


• anterior chamber clear


• ocular pressure 18 mm Hg


• posterior ocular exam unremarkable

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Scleritis

• opthalmology consult


• mild: oral NSAIDs


• refractory cases or evidence of scleral thinning (exposing underlying choroid): NSAIDs + oral corticosteroids/other immunosupressive drugs


• evaluate for potential complications: uveitis, keratitis or glaucoma


• evaluate for underlying systemic cause: rheumatoid arthritis (most common), Wegener's granulomatosis, systemic lupus erythematosus, inflammatory bowel disease, polyarteritis nadosa, infectious etiologies (herpes, Lyme, HIV)

Source

Dargin, J MD and Lowenstein, R MD. "The Painful Eye." Emergency Medicine Clinics of North America. 2008. 199-216.

Image: Dr. Frederick A. Jakobiec, eyepathologist.com