The Never Ending Red Eye

1. The Never Ending Red Eye November 21, 2002 Amanda Strom University Eye Center Grand Rounds

2. Personal Hx • 56 y/o BF first presented to UEC for CE 2/20/01 for “new glasses.” • POHx/PMHx: HTN x ? Yrs, eye pain with red eye, denied entire ROS • FOHx/FMHx: DM-Dad, Brother, Glc-Dad, Brother • Meds: Visine, “BP pill,” NKDA

3. Initial Exam Findings 2/20/01 • CHA OU c Presbyopia OU. • Dry Eye, all other SLE findings unremarkable. • HTN- “very mild ocular signs” • .35/.35 OU, PFR OU, Mild crossing changes OU. • Glaucoma Suspect (Ta 28 mm Hg OU) • RTC 2 wks later for VF and undilated exam: • IOP 16/18 OD, 24/20 OS • C/D 0.3/0.3 OD, 0.4/0.4 OS c possible superior notch. Slight VF defect corresponding to “notch” OS. • Monitor IOP, RTC 3 month for DFE.

4. 3 Months Later • RTC for DFE and VF (24-2) • IOP: 22 mm Hg OD, 24 mm Hg OS • VF: questionable nasal step OS • Deferred tx at that time. • Plan: • Recheck IOP in 6 mons • Gonioscopy 6 mons • VF in 1 yr. • 6 months later, no changes, status the same.

5. June 20, 2002 • RTC for “pressure check & I have a red eye.” • Pt reports: • itching & burning OU, redness OD x ? Days. • “1yr ago had red & px OS, but cleared up on its own.” • HTN Dx ’96 c “good control.”. • SLE: “Telengiectatic” Gr 3 bulbar nasal injection OD, - C/F, - px • IOP: 33 mm Hg OD, 26 mm Hg OS • Fundus: Macular Drusen OD>OS • Dx: Glc Suspect, Episcleritis • Tx: 1 gtt Lotemax qid OD & 1 gtt Lumigan hs OD. • RTC: 1 mon for IOP, VF, & Photos

6. June 28, 2002 (8 Days Later…) • Cc: OD red, photophobia, running tears, px (8/10 scale), • Pt denied UTI but confirms joint px (finger, elbow, knees) • IOP: 19 mm Hg OD, 24 mm Hg OS • SLE: Limbal flush OD, - discharge/mattering, - papillae/follicles, Gr II+ cells.

7. June 28, 2002 (cont.) • Dx: • Iritis- unkown etiology • Glc suspect • Tx: • D/c current eye meds • 1 gtt Cyclopentolate qd x 4 days OD • 1 gtt PF 1% qid x 8 days OD, then bid x 4 days, then qd x 1 day, then d/c. • RTC 7/1/02 for VF and FU.

8. July 1, 2002 • IOP: 28 mm Hg OD, 22 mm Hg OS • SLE OD: • Moderate engorged nasal scleral & episcleral vessels • Mild raised yellowish nodule • Trace ciliary flush • Dx: • Likely Nodular Scleritis OD, c resolving Uveitis. • VF: no changes consistent c glc; ocular HTN remains. • RTC 1 wk for DFE, cont. PF1% qid

9. July 9, 2002 (DFE) • SLE: • OD: nasal ciliary flush, - C/F • OS: clear • Fundus: • OD: choroidal nevus near ora, moderate crossing changes • OS: CWS!, moderate crossing changes • Telephone Consult c PCP: • BP 180/100, PCP to control HTN better, defer further testing to determine etiology of scleritis. • Pt continuing steroid taper at this time.

10. Follow Up 1 Month After Steroid Taper (8-26-02) • MY RED EYE IS BACK! • “OD is red, maybe even redder, no change in vision.” • Eye Meds: Finished • + Redness OD only, - itch, - burn, - photophobia, + tearing OD, - px! • VA unchanged from previous exams (20/20) • Pt reports last PCP Exam 7-9-02, when HTN med was increased.

11. SLE OD (video)

12. OD: Lids/Lashes: clear Conj: redness, engorged vessels nasally, 360 injection c heaped conj at 5o’clock Cornea: Prominent Schwalbe’s line c 360 Arcus, Round endo defect c 2 areas of K thinnning Iris: flat, -H/T A/C: - C/F OS: Lids/Lashes: clear Conj: mild nasal injection Cornea: 360 Arcus Iris: flat, -H/T A/C: -C/F SLE

13. 8/26/02 Exam Continued • BP: 158/90 • 1 gtt P 2.5% OD c some temporal & nasal blanching but no significant decrease in redness. • IOP (@ 6:05 pm) • 28 mm Hg OD • 14 mm Hg OS

14. Fundus: OD .35/.35, 2/3 A/V, Tortuous vessels Crossing changes along inferior arcade Faint Choroidal Nevus at Ora +PFR OS .35/.35, 2/3 A/V Crossing changes along inferior arcade Resolving CWS +PFR 8/26/02 Exam Continued:

15. 8/26/02 Exam Continued: • A: • 1. Atypical scleritis c no improvement in redness, no px, or photophobia • 2. Round endothelial defect c two new areas of corneal thinning nasal OD(?), likely 2’ to scleritis • 3. Unexplained increase in IOP OD.

16. 8/26/02 Exam (cont) • P: • 1. Counseled pt regarding atypical signs of scleritis. Discussed FU phone call c PCP for lab work-up to R/O systemic associations. HTN uncontrolled? RTC for EHMS c MD 9/4. • 2. Monitor new corneal finding, discuss c PCP to motivate for lab work-up and systemic associations. • (3. No medications Rx’ed at this time).

17. 1 Week Later: EHMS • Increased scleral/epscleral engorgement OD • Increased K edema • Slight increase in “heaping” of conjunctiva • K thinning difficult to assess 2’ to conjunctival view • Some vessel engorgement nasally • A/C: OCCASIONAL CELLS OD!

18. EHMS (9/2/02) • Dr. Culican initiated: • Prednisone 80 mg/day x 4 days, 60 mg x 4 days, then 40 mg until FU. • Pt to FU in 2 weeks.

19. My FU #1 • “OD getting better c prednisone” • Chest X-Ray 9/6/02 (patient brought report to appt.): • Borderline heart size • Hilar & mediastinal calcifications are present • Small calcified nodules bilaterally • Compatible c granulomata • No hilar adenopathy

20. MY FU # 1 • SLE: • NO C/F! • Still edematous conj c MILD corneal thinning • IOP (@ 7:30 pm) • 24 mm Hg OD • 23 mm Hg OS • Pt to continue oral pred taper • RTC 1 week

21. MY FU # 2 • No px or photophobia, much decreased redness and K edema from one week prior. • IOP (@8:00 pm ): • 21 mm Hg OD • 24 mm Hg OS • TBUT: 3-4 secs • P: continue oral pred taper

22. MY FU # 2 SLE OU (video)

23. MY FU # 3 & 4 • EVEN BETTER! • Continuing to resolve c taper: • As of 10/2/02 pt was beginning last taper: • 15 mg x wk, 10 mg x 1 month, then to 5 mg x 1 mon. • Pt scheduled appt. with Dr. Van Gelder (tertiary care inflammatory eye disease) at BRI on 11/6/02, for consult on systemic etiology of scleritis and further mgmt. with high risk meds

24. Connective Tissue Dz: RA Wegener’s Granulomatosis Relapsing Polychondritis SLE Reiter’s Syndrome Polyarteritis Nodosa Ankylosing Spondylitis Herpes Zoster Ophthalmicus Syphilis After ocular surgery Gout TB Lyme Dz Sarcoidosis HTN FB Parasite Etiologies of Scleritis

25. CBC ESR Uric Acid RPR FTA-ABS RA Factor ANA Fasting Blood Sugar ACE PPD c Diff Chest Radiograph of sacroiliac joints B- scan MRI CT Diagnostic Tests

26. Idiopathic (most common) Collagen Vascular Dz Gout Infectious Etiologies of Episcleritis

27. BRI, Dr. Van Gelder (11/6/02) • Eye “fairly quiet”; smoldering episcleritis and scleritis • Lab Orders: • CBC, CMP, ACE, ANA, HLA-B27 • CMP= albumin, bilirubin, Ca, Carbon Dioxide, chloride Creatinine, alkaline Phosphatase, K, Protein, Na, AST, Urea Nitrogen, Glucose, ALT • ALL NORMAL!

28. Dr. Van Gelder • Rx PF 1% to manage episcleritis; d/c PO Pred to allow subsequent examination of full-blown scleritis (Dr. Van Gelder had not yet seen patient with maximum signs) • F/u 1 month • PEARL: FML Forte sometimes works better than PF on both episcleritis and scleritis, though it doesn’t penetrate cornea as well.

29. Per Dr. Van Gelder • 50% of pts c scleritis have unknown etiology • Mgmt Options: • Indomethacin 25-50 mg tid (for moderate dz) • Cyclosporin (not as good, long term risk Renal Failure & HTN 20%!) • Many patients never improve with any Tx; may have for their entire life

30. “Atypical Scleritis” • No pain • Diffuse Sectoral Scleritis • +/- photophobia (off and on) • No bluish scleral hue

31. Corneal Thinning • Corneal changes occur in ~50% of pts c nodular scleritis, 40% of pts c nectrotizing scleritis, & 20% of pts c diffuse scleritis… nodular scleritis tends to be associated with local corneal changes adjacent to areas of scleral inflammation… • Pepose!

32. The Never Ending Red Eye • This patient may likely need to be on continuous steroid therapy control for outbreaks. • The most common etiology of episcleritis is idiopathic; scleritis only has an underlying cause 50% of the time (PEPOSE).

33. The End