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Inflammatory disorders (PEARLS)

PANCE Blueprint EENT (6%)

Iritis
Patient will present as → a 32-year-old woman with a history of ankylosing spondylitis presenting with redness, eye pain, and photophobia in the right eye. She denies trauma or discharge but reports blurry vision. On examination, her right eye has a circumferential redness near the corneal limbus (ciliary flush), a small, irregularly shaped pupil, and cells and flare in the anterior chamber on slit-lamp examination. Iritis (anterior uveitis) is suspected, and she is urgently referred to an ophthalmologist for evaluation and management.

Iritis (anterior uveitis) is an inflammation of the iris, commonly associated with autoimmune diseases or infections, leading to ocular pain and visual impairment

  • Symptoms include eye pain, redness (particularly near the limbus), photophobia, blurred vision, and sometimes a small or irregular pupil
  • May occur in association with systemic conditions such as ankylosing spondylitis, reactive arthritis, sarcoidosis, or infections (e.g., herpes, syphilis, tuberculosis)
  • Physical exam findings include ciliary injection, a consensual photophobia response, and in severe cases, the presence of hypopyon or keratic precipitates on slit-lamp examination

DX: Diagnosis is clinical, often confirmed by slit-lamp examination showing inflammation in the anterior chamber (e.g., cells and flare)

TX: Referral to an ophthalmologist is essential for proper diagnosis and management

  • Topical corticosteroids (e.g., prednisolone drops) to reduce inflammation and cycloplegic agents (e.g., atropine) to relieve pain and prevent synechiae
  • Systemic workup may be necessary to identify underlying autoimmune or infectious causes in recurrent or bilateral cases
  • Complications include posterior synechiae, glaucoma, and vision loss if not treated promptly
Scleritis
Patient will present as → a 42-year-old female with rheumatoid arthritis presents with deep, aching pain in her right eye, worsening with movement, along with redness and blurred vision. Examination reveals diffuse redness involving the sclera with tenderness on palpation. Slit-lamp exam confirms scleral inflammation, consistent with diffuse anterior scleritis. Management includes systemic NSAIDs (e.g., indomethacin) and referral to a rheumatologist for possible immunosuppressive therapy. Follow-up with ophthalmology is necessary to monitor for complications.

Inflammation of the sclera (the white outer coating of the eye) associated with systemic immunologic disease, such as rheumatoid arthritis

  • It causes significant eye pain (severe, deep pain), redness, photophobia, and reduced vision; pain often worsens with eye movement

DX: On examination, there is ocular redness and pain on palpation of the eyeball. It can cause visual impairment

  • Labs should include screening for systemic immunologic diseases - ANCAs, ANA, CRP, ESR, Lyme, RA, ACE, RPR, etc.

TX: Refer the patient for prompt evaluation by an ophthalmologist

  • NSAIDs (e.g., indomethacin) are effective for mild cases like diffuse or nodular anterior scleritis
  • Glucocorticoids (e.g., prednisone 1 mg/kg/day) for severe cases or those unresponsive to NSAIDs
  • Immunosuppressive agents (e.g., methotrexate, mycophenolate mofetil, or cyclophosphamide) for necrotizing scleritis or systemic disease involvement
  • Biologic therapies (e.g., rituximab or TNF-alpha inhibitors) for refractory or severe cases
Pterygium (ReelDx + Lecture) (Prev Lesson)
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