Man with a painful red eye

A 38-year-old man presented to the emergency department (ED) with a 1-week history of left eye pain and redness (Figures 1-3). The eye pain radiated to his left forehead and was temporarily relieved by ibuprofen. He denied any associated change in his vision. On examination, his eye was diffusely injected, most prominently on the superior and lateral aspects. Instillation of 2.5% phenylephrine eye drops did not significantly change the injection.

Scleritis is a rare, vision-threatening inflammation of the sclera. It occurs most commonly in the middle-aged, with women more commonly affected.¹ Up to 50% of cases of scleritis occur in the setting of systemic autoimmune disease, most commonly rheumatoid arthritis.² Scleritis may be due to infectious causes, medication-induced, or occurring after intraocular surgery, and many cases are idiopathic.²

Patients with scleritis present with an injected, painful eye. The eye pain may radiate to the jaw, forehead or scalp, and is typically worse at night.³ The involved eye is usually diffusely injected, though the injection may be localized and nodular in appearance.⁴ As with this case, installation of topical vasoconstrictor agents such as phenylephrine will not cause a blanching of the injected vessels with scleritis, as it would with conjunctivitis and episcleritis. Further evaluation and treatment of scleritis in the ED should ideally be discussed with an ophthalmologist and may include investigations for rheumatologic and infectious etiologies. Oral nonsteroidal anti-inflammatory drugs and topical corticosteroids are considered first-line therapy for cases of noninfectious scleritis such as this.