A 58-year-old patient presents complaining of the recent, gradual onset of deep, boring left eye pain with tearing, decreased vision, and redness over the past several days. The pain is referred to the adjacent facial and head regions, and the patient tells you that it is more severe at night and awakens him during sleep.
On examination of the external eye, you note multiple dilated vessels that cannot be moved with a cotton applicator (see Figure 1).
Figure 1.
The cornea and the periorbital skin are normal in appearance. Slit-lamp examination is significant for scleral edema.
The patient is most likely experiencing what condition?
Episcleritis is a benign inflammation of the episcleral tissues. Tenderness is usually absent, pain is mild, and the deep sclera is white. It tends to occur in healthy young patients and is usually self-limited (7-10 days), but it may recur in up to 50%. A systemic cause is usually not found. It can be treated with topical vasoconstrictors, anti-inflammatory agents or a combination of both. Episcleritis also presents with dilated vessels, but these vessels are (and appear) more superficial than those in scleritis. Ocular redness is most often the patient’s chief complaint. In addition, pain (or absence thereof) is a distinguishing feature between scleritis and episcleritis.
Ocular herpes zoster occurs most often in the elderly. Suspect an immunosuppressive condition in younger patients with this condition. Treatment may include acyclovir and ganglion blockade to decrease symptoms and reduce the risk of postherpetic neuralgia.
References:
Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, Doctor PP, Tauber J, Foster CS. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119(1):43-50.
Watson P, Romano A. The impact of new methods of investigation and treatment on the understanding of the pathology of scleral inflammation. Eye. 2014;28(8):915-930.
Wikimedia Commons website. Scleritis. Published January 8, 2011. Accessed June 20, 2018.
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