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)
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