Source: Alcon Laboratories
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Problem:
A 55-year-old woman presents to your emergency department with a chief complaint of “conjunctivitis,” according to the triage sheet. You call the patient to the examination room. She reports no significant medical history and tells you she is visiting from Puerto Rico. About three days ago, she began noticing irritation in her right eye, and subsequently the eye became red with increasing pain and tearing. Her vision has remained intact. She does not use corrective or contact lenses. She denies any trauma or exposure to foreign bodies.
Your examination reveals a high degree of redness of her right eye. At 20 feet, her visual acuity is 20/40 uncorrected in her left eye and 20/60 in the affected eye. The eyelids and lashes are normal. The conjunctiva is hyperemic, especially the bulbar conjunctiva on the temporal side of the right globe. There is no cobblestoning of the palpebral conjunctiva; the cornea and anterior chamber are clear. Slit-lamp examination of the eye reveals no evidence of a foreign body. The anterior chamber of the eye is without “cells and flare” (cells or protein in the aqueous humor of the anterior chamber). Tonometry reveals an intraocular pressure of 16 mm Hg (10 to 22 mm Hg is normal). Fluorescein staining demonstrates no sign of corneal uptake. The fundoscopic exam is normal, and there is no preauricular lymphadenopathy.
You tell the patient that this is likely a mild case of conjunctivitis. You explain that the two most common infectious causes are viral and bacterial and that both are highly contagious. You inform her that you will prescribe an antibiotic ointment and have her follow up with an ophthalmologist in a day or two.
The patient becomes annoyed and tells you that this is her third episode of right eye pain and redness in six months. On the last two occasions her primary physician in Puerto Rico treated it with antibiotic eye drops. She does not recall the name of the drops but on both occasions the condition resolved in a few weeks. She would like to know why this “conjunctivitis” keeps returning.
What diagnosis were you about to miss?
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Answer:
Both history and physical exam clues were missed. The recurring nature of this patient’s condition should have been elicited before she offered that key piece of information herself. It would have raised suspicion that this was not likely an infectious process.
Allergic conjunctivitis (top) is perhaps the most common cause of recurrent noninfectious conjunctival inflammation. However, unilateral involvement, no previous history of seasonal or other allergies, very episodic occurrence and a recurrence after a significant environmental change (visiting the northeastern United States from her native Puerto Rico) seem to make this diagnosis less likely.
A physical exam clue provides the true answer. The clue is found by close inspection of the sclera, conjunctiva, and episclera. In this case, one notices the loss of the white appearance of the globe beneath the dilated conjunctival blood vessels. The episclera and sclera appear diffusely erythematous.
This patient is presenting with a case of episcleritis, an inflammation of the episclera. The cause is usually idiopathic, although there have been associations with rheumatoid arthritis, Sjögren syndrome, syphilis, herpes, and tuberculosis. Symptoms include eye pain, redness, tearing, and sometimes visual impairment. The course is usually self-limited, resolving without treatment in one to two weeks. Relapses, however, are common and in rare instances episcleritis will progress to scleritis. Topical corticosteroids can shorten the duration of symptoms. A work-up for an associated or underlying systemic illness should be undertaken.
Had this patient presented with scleritis (bottom), it would have been a greater concern. The presentation may be similar, but the pain is usually more severe and visual acuity more likely to be affected with scleritis. Complications include the formation of cataracts, secondary glaucoma, retinal detachment, optic atrophy, and even globe rupture. Episcleritis tends to involve a focal patch of the eye, rather than the entire eye as in scleritis. In scleritis, cells and flare may be present if anterior chamber inflammation exists. Differentiation between episcleritis and scleritis can be made by determining the depth of the inflammation by slit-lamp examination and the response of hyperemia to the vasoconstrictive effect of sympathomimetic eye drops. The more superficial dilated blood vessels in episcleritis will vasoconstrict and the white of the sclera will return; the deeper vessels involved in scleritis will not vasoconstrict to the same degree, leaving the sclera erythematous. This evaluation can be left to an ophthalmologist, who should be consulted in these types of cases.
In this case, the patient was unlikely to have suffered any adverse health effects from her episcleritis since it would have resolved on its own. However, it would have likely recurred and continued to be misdiagnosed. Had this been scleritis, permanent damage to the eye could have ensued from failure to make the proper diagnosis.
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