A Young Woman With Unilateral Eye Pain and Erythema

Thalia Salinas; Rod Foroozan, MD


April 10, 2014

Clinical Presentation

A 30-year-old woman was referred for evaluation of a 6- to 7-day history of eye pain and redness in the right eye. She reports air and light sensitivity but denies vision loss. She has had some body aches, but no fevers or chills.

The patient was seen in the emergency department 2 days ago, where she was found to be afebrile and normotensive. She had CT of the brain and blood tests, which were normal. She was given moxifloxacin hydrochloride eye drops.

Her medical history includes moderately well-controlled diabetes mellitus (diagnosed 2 years ago) and hypothyroidism. Her medications include liraglutide, sitagliptin/metformin hydrochloride, glimepiride, levothyroxine, vilazodone hydrochloride, and pantoprazole.

About 1.5 years ago, she saw her primary care physician for eye pain and swelling in the right eye and was given allergy medication. She has taken steroid medication, the most recent use being 2 years ago for a sinus infection and postpartum sciatica. Seven years ago, she had an MRI of the brain for visual aura and was diagnosed with viral meningitis. She denies smoking, alcohol use, and other drug use.

Ophthalmic Examination

At the time of presentation, the patient's visual acuity was 20/20 in each eye. Both pupils were symmetric and brisk, with no relative afferent pupillary defect. Visual fields by confrontation were full. Extraocular movement was full.

Ocular alignment showed that the patient was orthotropic in 9 positions of gaze and near by alternate cover testing. Amsler grid testing was normal. Color vision with Ishihara pseudoisochromatic plates was 10/10 in both eyes. Intraocular pressure was 12 mm Hg in each eye.

Slit-lamp examination of the right eye showed conjunctival and episcleral injection diffusely and chemosis nasally and inferiorly. The sclera on the right was noted to have a deeper violaceous color compared with the left eye. Slit-lamp examination of the left eye was normal. There were no cells in the anterior chamber or vitreous.

The funduscopic examination was normal on each side, with no optic disc pallor, a normal-appearing macula, and a cup-to-disc ratio of 0.25 on the right and 0.35 on the left. The injection of the right eye persisted after pharmacologic mydriasis with 2.5% phenylephrine.

Imaging Studies

MRI of the patient's brain and orbits with contrast showed abnormal enhancement of the posterior aspect of the right globe (Figure). There was no enhancement within the globe or the optic nerve. MRI of the brain was unremarkable.

Figure. T1 axial MRI with contrast of the orbits, showing abnormal enhancement involving the sclera of the right eye.


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