Description: When looking at Figure 3.1, my attention is directed toward a dilated pupil that exposes a crystalline lens with multiple levels of discolored opacification in various configurations and at various depths within the lens.

Differential Diagnosis: Given the image in Figure 3.1, the age of the patient, and the patient’s history, my diagnosis is a cataract. In general, cataracts can be congenital or acquired. Acquired cataracts can be due to drugs, systemic diseases, trauma, and age. In this case, I believe the cataract is most likely due to age. Other causes for painless decrease in vision loss include diseases of the nerve such as glaucoma and retinal diseases such as age-related macular degeneration. The examination would help support or refute my working diagnosis.

History: In this patient, I expect and I would ask about increased glare, decrease in color vision, and need for more light when reading the newspaper. I would also ask about systemic issues such as diabetes, steroid use, radiation, trauma, and the use of urinary retention medications.

Exam: To confirm my diagnosis of an acquired age-related cataract, I would need to examine the other eye for a similar level and type of cataract. But first, I need to rule out other etiologies for vision loss by evaluating the pupil, retina, and nerve.

Workup: The workup would consist of ruling out other causes for the decrease in vision. An optical coherence tomography (OCT) would help us determine the structural integrity of the nerve and macula. Of course, I would also obtain axial length and keratometry readings to determine the power of the intraocular lens (IOL).

Treatment: Mild cataracts are treated with corrective glasses. In this case, the best glasses cannot improve my patient’s vision to the level he desires, so I would offer surgery.

Advice: I would educate the patient that his “white pupil” is actually a cataract. A cataract is when the human lens becomes opaque and cloudy. The patient should consider surgery if he needs or desires better vision to improve the quality of daily activities.

Follow-up: If the patient decides to proceed with surgery, he needs to follow our preoperative and postoperative instructions to prevent complications. If no other ocular diseases are present, I plan to provide postoperative care to my patient on post-op day 1, post-op week 1, post-op month 1, post-op month 3, and post-op month 6.

Description: My attention is drawn to the injected temporal area that is consistent with nodular scleritis with associated scleral thinning (Fig. 3.2). I do not see corneal disease in this image.

Differential Diagnosis: My top differential diagnosis is scleritis. The most common type of scleritis is nodular, whereas necrotizing scleritis is the most severe. The causes for scleritis are collagen vascular diseases (rheumatoid arthritis, systemic lupus, polyarteritis nodosa), vascular diseases (Wegener granulomatosis, giant cell arteritis, Takayasu disease), inflammatory bowel diseases (ulcerative colitis, Crohn disease), and infectious etiologies (syphilis, tuberculosis, herpes simplex virus).

History: The character of the pain is important to this diagnosis. For scleritis, I would look for the pain to be a “boring” pain that often radiates to the forehead and jaw. I would inquire if the pain awakens her at night. I would also ask about the acuteness of onset and if she has any visual changes. I would investigate the patient’s medical history, specifically looking for autoimmune and rheumatologic diseases. I am concerned to learn if the patient’s miscarriages were ever evaluated.

Exam: On examination, I would visualize the sclera in all directions of gaze, slit lamp examination with green light, and dilated fundus examination. The purpose of the examination is to determine the level of tissue inflammation and differentiate between episcleral and scleral inflammation as well as rule out posterior involvement. This method of examination would confirm the diagnosis is scleritis. I would want to consider nodular vs necrotizing scleritis, necrotizing being the more serious diagnosis. I would be especially careful to note “violaceous hue” signaling thinning of the sclera by exposure of the underlying uveal tissue. With nodular scleritis, I would expect a thickened sclera.

Workup: Phenylephrine 2.5% solution would not reduce the inflammation and vessel engorgement in scleritis as it does in episcleritis, indicating to me the gravity of the pathology. With concern for an associated systemic disease, I would order the following lab analyses: antinuclear antibodies for systemic lupus erythematosus, rheumatoid factor for rheumatoid arthritis, erythrocyte sedimentation rate and C-reactive protein for vasculitides, serum uric acid levels, fluorescent treponemal antibody absorption for syphilis, and anti-neutrophil cytoplasmic antibody for Wegener disease. I would also place a rheumatology consult as patients who present with necrotizing scleritis have a 25% 5-year mortality associated with systemic autoimmune diseases. In patients in whom I suspect infectious origin, I would obtain blood cultures.

Treatment: For necrotizing scleritis associated with systemic autoimmune disease, I would treat with aggressive systemic steroids and immunosuppressive therapy, followed by a slow taper of the immunosuppressive agents. Scleral patching may be performed if there is a risk of scleral perforation after the inflammation begins to subside. Aggressive systemic treatment is warranted because of increased risk of mortality secondary to coronary arteritis and cerebral angiitis, associated with autoimmune disease.

Advice: I would indicate to the patient the significant relationship between scleritis and serious systemic illness. I would stress the importance of adhering to my recommended visits to internist and specialists as indicated by the lab workup results.

Description: The anterior slit lamp photograph of the left eye reveals a 2-mm hyphema. The source of the bleeding is located in the superior iris. I do not see any evidence of external trauma such as corneal abrasions, corneal edema, or external orbit contusions.

Differential Diagnosis: Given the presentation, the diagnosis is an iatrogenic hyphema secondary to laser peripheral iridotomy. My differential diagnosis includes other causes of hyphema such as trauma, rubeosis iridis, tumors, uveitis, and blood disorders.

History: Because trauma is the number one cause of hyphema, I would sensibly ask the patient if he has had recent trauma or Valsalva maneuvers. The history and timing of a laser peripheral iridotomy point to the diagnosis of an iatrogenic-induced hyphema. I would also ask about use of blood thinners and blood disorders.

Exam: After ruling out a ruptured globe, I would check intraocular pressure (IOP) because elevated IOP is a known complication of laser peripheral iridotomy and hyphemas. With gonioscopy, I would determine the exact origin of the bleeding; and if the bleeding is still active, I would apply gentle pressure for 10 seconds at a time, with the same gonioscope, to stop the bleeding. If I am unable to stop the bleeding with gentle pressure, I would use argon laser to cauterize the bleeding iris.

Workup/Testing: I would reevaluate the patient in 20 minutes to determine the IOP because the hyphema, laser peripheral iridotomy, and the condition being treated can all cause elevated IOP.

Treatment: I would start treating this hyphema with aqueous suppressants and ophthalmic steroids every 2 hours. I would avoid cycloplegics because they can induce angle-closure glaucoma in this patient. I would ask that the patient avoid severe manipulation of the eye and any strenuous activity including Valsalva.

Advice: If the patient is taking blood thinners, I would not stop them because that can lead to systemic complications such as strokes and heart attacks. With proper treatment and follow-up, there is a high probability this hyphema will not permanently affect his vision or health of the eye. Because the patient underwent laser peripheral iridotomy, there is still a risk for retinal detachment, so I would give the patient both retinal detachment warnings and hyphema warnings. In essence, the patient needs to call if his vision worsens or if he develops eye pain.