conjunctivitis vs scleritis

[RevEM]

Hi ophtho gang,
I am about to start my emergency medicine residency and have been doing some reading on cases I wrote down during my rotations last year.
I saw a pt twice during my EM rotation and initially we diagnosed conjunctivitis but she came back the next day and had an ophtho consult and the dx was anterior scleritis. I've been doing reading on both and they sound pretty similar to the non eye specialist so I was wondering if any of you experienced folks could offer some tips on differentiating them. The treatment is very different so I am going to need to know this very well. Any help is appreciated.
Thanks,
Rev

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[MR1]

Oh the "red eye". Diagnosing scleritis is gonna be hard for the non-ophtho. Some clues though, scleritis often has a very dull, boring pain and when you push on the eye, they will come off the table on you. The injection also will not blanch completely when you put neosynephrine in the eye (if you even have that available). Sometimes it is nodular and you will see a nodular granulomatous reaction on the conj.

I wouldn't stress about being able to diagnosis this, the morbidity in missing it is low, they won't get better so they'll come back or get seen by ophtho fairly soon. Also it isn't very common.

Besides conjunctivitis when you see a red eye, you really should focus on telling the difference between angle closure glaucoma and iritis\uveitis.

 

[MstaKing10]

A red eye has a broader differential than just the two mentioned. However, usually the history can tell you a lot. If there is a history of recent URI, sick contacts, or findings of discharge, pre-auricular lymphnodes, follicles on the conjunctiva, corneal findings or the like it may be more of a conjunctivitis. Scleritis is usually more of a violet color, more painful, doesn't blanch with neo, may be associated with iritis component, and can sometimes be linked to a systemic/autoimmune disease.

As mentioned above, prompt outpatient f/u for these is reasonable, however, more emergent things like angle closure need to be dealt with immediately.

 

[speyeder]

As an emergency medicine physician, you are not expected to be able to diagnose scleritis. Rather, you must be able to sort through the many causes of a red eye and know when to refer the patient to an ophthalmologist.

Conjunctivitis a catchall phrase for inflammation of the conjunctiva and the superficial conjunctival blood vessels. Typically the hyperemia is diffuse. In allergic conjunctivitis the predominant complaint is itching but usually there's no discharge. In bacterial conjunctivitis the predominant symptom is copious purulent discharge. In viral conjunctivitis, symptoms can be vague but look for preceding or concurrent URI symptoms, lymphadenopathy and a history of redness in one eye followed shortly by redness in the other eye (self innoculation).

Scleritis is inflammation of the deeper scleral vessels. As a poster previously mentioned, the scleral vessels classically have a violaceous or purple hue to them. This can be difficult to appreciate without the aid of a slitlamp. The hyperemia in the eye can be localized or diffuse. Helpful in the diagnosis is the fact that in scleritis, the vessels do not blanche after applying phenylephrine drops (conjunctival vessels do blanche). However I suspect most EM physicians do not routinely dilate patients so this may not be helpful to you. Finally the hallmark of scleritis is pain. It is described as a deep, boring type of pain, which is exacerbated by palpating the eye. If a patient truly has scleritis, I would expect him or her to almost jump out of the chair if I press on their eyeball. In patients with scleritis, 50% or more will have some underlying rheumatological condition. Scleritis is a potentially vision-threatening condition and patients should be promptly referred to an ophthalmologist.

In general, you should consider calling ophthalmology for any patient who presents with a red eye and pain.