History of Present Illness
A 75-year-old female with past medical history significant for hypertension, chronic kidney disease, and a prior carotid endarterectomy of the left internal carotid presented with acute-onset blurry vision, tearing, eye pain, and redness of the right eye (OD).
| OD | OS | |
|---|---|---|
| Visual acuity | 20/25−2 | 20/20−2 |
| Intraocular pressure (IOP) | 14 | 14 |
| Sclera/conjunctiva | White and quiet | White and quiet |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | Deep and quiet | Deep and quiet |
| Iris | Unremarkable | Unremarkable |
| Lens | Clear | Clear |
| Anterior vitreous | Clear | Clear |
| Posterior segment | Choroidal folds | Within normal limits |
Because of the finding of choroidal folds, optical coherence tomography (OCT) and ultrasound were performed ( Figs. 27.1 and 27.2 ).
Questions to Ask
- •
Do you have ocular pain, with or without eye movement?
- •
Do you have an associated systemic rheumatic disease, autoimmune disease, or systemic vasculitis or is there any family history of such diseases?
- •
Do you have any sinus issues, including epistaxis?
- •
Do you have a history of a sexually transmitted disease or exposure to other infectious diseases?
- •
Do you have a history of ocular or systemic neoplastic disease?
She answers yes to ocular pain with and without eye movement. Otherwise, she answers no.
Assessment
- •
Unilateral posterior scleritis OD
Systemic Disease Associations
- •
Rheumatoid arthritis
- •
Granulomatous polyangiitis
- •
Polyarteritis nodosa
- •
Ankylosing spondylitis
- •
Psoriasis
- •
Systemic lupus erythematous
- •
Sarcoidosis
- •
Tuberculosis
- •
Syphilis
Differential Diagnosis
- •
Choroidal tumor (melanoma, hemangioma, metastasis)
- •
Orbital neoplasia (immunoglobulin G [IgG] 4–related disease)
- •
Annular ciliochoroidal detachment
- •
Exudative retinal detachment
- •
Choroidal neovascularization (CNVM)
- •
Central serous chorioretinopathy (CSCR)
- •
Vogt-Koyanagi-Harada disease (VKH) (bilateral posterior scleritis)
- •
- •
Uveal effusion syndrome
Working Diagnosis
- •
Idiopathic posterior scleritis OD
Testing
- •
In patients with classic presentations, such as the woman described here, testing for systemic rheumatologic, autoimmune, and noninfectious diseases should be undertaken to identify potentially treatable conditions that might affect systemic health, morbidity, and mortality, as well as to exclude infectious diseases before the introduction of systemic treatment with steroids or immunomodulatory therapy (IMT).
- •
For most cases check:
- •
Fluorescent treponemal antibody absorption (FTA-ABS), rapid plasma reagin (RPR)
- •
Purified protein derivative (PPD) or QuantiFERON gold
- •
Rheumatoid factor, anti-cyclic citrullinated peptide antibody (CCP)
- •
Cytoplasmic antineutrophil cytoplasmic antibodies (cANCA) and perinuclear antineutrophil cytoplasmic antibodies (pANCA) with myeloperoxidase (MPO)/proteinase 3 (PR-3) antibodies
- •
Antinuclear antibodies (ANA)
- •
Angiotensin-converting enzyme (ACE), lysozyme, and chest x-ray
- •
HLA-B27
- •
Complete blood count (CBC), complete metabolic panel (CMP)
- •
- •
Patients should be periodically asked about the development of associated symptoms, such as joint pain, sinus issues/epistaxis, shortness of breath, and skin rashes.
Management
- •
Oral prednisone taper once the results of infectious laboratory tests have returned (60 mg for 2 weeks then 50 mg, 40 mg, 35 mg, 30 mg, 25 mg, 20 mg, 15 mg, 10 mg, and 5 mg for 1 week each)
- •
Follow up in 1 month with repeat ultrasonography
- •
Refer to rheumatology if associated systemic autoimmune disease is identified during workup
Follow-up
The patient follows up 1 month later. She reports nearly complete resolution of her symptoms. Vision is 20/25 both eyes (OU) ( Fig. 27.3 ).
