A Young Woman With Unilateral Eye Pain and Erythema

Thalia Salinas; Rod Foroozan, MD


April 10, 2014

Case Diagnosis

The correct diagnosis will be described first, followed by the differential diagnosis and why these etiologies for the patient's symptoms can be ruled out.

Scleritis. This patient is experiencing ocular pain with chemosis and injection of the deeper anterior segment vessels. Ocular pain is often the chief symptom in scleritis. The pain may be moderate to severe and constant, and typically worsens with movement caused by the insertion of the extraocular muscles into the sclera. The deeper violaceous color characteristic of scleritis is the result of the dilation and engorgement of both superficial and deep episcleral vessels.

Episcleritis. Episcleritis is usually painless, self-limited, and less likely to be associated with a systemic autoimmune condition. It would not result in the deeper violaceous scleral injection seen in this patient. Rather, examination would reveal dilated, superficial episcleral vessels in a radial pattern with white sclera observed in between.[1] These dilated vessels may be moved with a cotton-tipped applicator and blanch with phenylephrine.

Conjunctivitis. Patients with conjunctivitis usually have painless, diffuse conjunctival hyperemia, along with other signs and symptoms depending on the causative agent.

Patients with allergic conjunctivitis present with bilateral itching and watery discharge. Patients with viral conjunctivitis may have tearing, a foreign body sensation, conjunctival injection and chemosis, lid edema, and preauricular lymph node enlargement.

Bacterial conjunctivitis usually presents with lid edema and purulent discharge. A follicular or papillary reaction of the palpebral conjunctivae may be observed.

This patient had received treatment with moxifloxacin, a broad-spectrum agent, for 2-3 days without any improvement.

Blepharitis. This refers to acute or chronic inflammation of the eyelid and is commonly associated with conjunctival inflammation. This patient did not report ocular irritation, tearing, a foreign body sensation, or crusting of the eyelashes. Examination did not reveal erythema or edema of the eyelid margins; crusting, misdirection, or loss of eyelashes; oil inspissation; or instability of the preocular tear film.[1]

Subconjunctival hemorrhage. This would be asymptomatic, except for focal and well-circumscribed hemorrhage beneath the bulbar conjunctiva. The underlying sclera would not be visible, and there would be no inflammation of the conjunctiva.[1]

Keratoconjunctivitis sicca. This patient did not experience a foreign body sensation, burning, or a worsening of symptoms throughout the day. There was no irregularity of the corneal surface or a reduced tear lake upon examination. [2]

Anterior uveitis. Although this patient had ocular pain and light sensitivity, the injection seen in anterior uveitis is typically around the limbus, overlying the inflamed ciliary body. This patient's examination did not reveal proteinaceous flare or inflammatory cells circulating in the anterior chamber. Her pupils were not irregular, or poorly reactive to light, which can result from synechiae between the iris and lens in anterior uveitis.


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