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A Middle-aged Man With Bilateral Eye Redness and Pain

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 68-year-old man presented to the clinic with bilateral eye redness and pain for the past 6 months. He had a history of dry eye disease for which he was treated with preservative-free artificial tears. He also noted a medical history of well-controlled HIV with highly active antiretroviral therapy. His last CD 4 lymphocyte count was 750 cells/mm3 with an undetectable viral load. A review of system produced negative results, including absence of weight loss, fevers, headache, joint pain, respiratory symptoms, or skin rash. The patient reported having unprotected sexual contact with multiple male partners in the past few years.

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Bilateral syphilitic scleritis

C. Laboratory work-up for infectious and autoimmune disease

Topical phenylephrine is used to differentiate episcleritis from scleritis. Episcleritis causes congestion of superficial episcleral vessels, which constrict when exposed to phenylephrine, whereas scleritis causes congestion of deeper vessels, which are not significantly affected by phenylephrine.1

Scleritis is often associated with a systemic disease, so further investigation is recommended prior to starting treatment (choice C).2 Differential diagnosis includes autoimmune causes (rheumatoid arthritis, granulomatous polyangiitis, relapsing polychondritis, etc) and infections (syphilis, herpes viruses, etc).1,2 Work-up should be tailored to clinical presentation and review of systems and includes serum autoantibody testing (rheumatoid factor, antineutrophil cytoplasmic antibodies, antinuclear antibodies, etc), sarcoidosis screening, syphilis testing, urinalysis, and others.13 Nodular and diffuse anterior scleritis often respond to oral nonsteroidal anti-inflammatory drugs (choice A).2 Corticosteroids (choice B) and systemic immunosuppression are recommended for patients who do not respond or necrotizing scleritis.1,3 Topical corticosteroids (choice D) can reduce inflammation, but systemic treatment is often required.1

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Article Information

Corresponding Author: Parisa Emami-Naeini, MD, MPH, Department of Ophthalmology and Vision Science, University of California, Davis, 4860 Y St, Ste 2400, Sacramento, CA 95817 (parisaemami@gmail.com).

Published Online: October 14, 2021. doi:10.1001/jamaophthalmol.2021.1451

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Watson  PG , Hayreh  SS .  Scleritis and episcleritis.   Br J Ophthalmol. 1976;60(3):163-191. doi:10.1136/bjo.60.3.163PubMedGoogle ScholarCrossref
2.
Jabs  DA , Mudun  A , Dunn  JP , Marsh  MJ .  Episcleritis and scleritis: clinical features and treatment results.   Am J Ophthalmol. 2000;130(4):469-476. doi:10.1016/S0002-9394(00)00710-8PubMedGoogle ScholarCrossref
3.
Akpek  EK , Thorne  JE , Qazi  FA , Do  DV , Jabs  DA .  Evaluation of patients with scleritis for systemic disease.   Ophthalmology. 2004;111(3):501-506. doi:10.1016/j.ophtha.2003.06.006PubMedGoogle ScholarCrossref
4.
Singh  AE , Romanowski  B .  Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features.   Clin Microbiol Rev. 1999;12(2):187-209. doi:10.1128/CMR.12.2.187PubMedGoogle ScholarCrossref
5.
Foster  C , Vitale  A.   Diagnosis & Treatment of Uveitis. JP Medical Ltd; 2013.
6.
Adams  DA , Thomas  KR , Jajosky  RA ,  et al; Nationally Notifiable Infectious Conditions Group.  Summary of notifiable infectious diseases and conditions: United States, 2015.   MMWR Morb Mortal Wkly Rep. 2017;64(53):1-143. doi:10.15585/mmwr.mm6453a1PubMedGoogle ScholarCrossref
7.
Kiss  S , Damico  FM , Young  LH .  Ocular manifestations and treatment of syphilis.   Semin Ophthalmol. 2005;20(3):161-167. doi:10.1080/08820530500232092PubMedGoogle ScholarCrossref
8.
Marra  CM .  Syphilis and human immunodeficiency virus: prevention and politics.   Arch Neurol. 2004;61(10):1505-1508. doi:10.1001/archneur.61.10.1505PubMedGoogle ScholarCrossref
9.
Workowski  KA , Bolan  G ; Nationally Notifiable Infectious Conditions Group.  Sexually transmitted diseases treatment guidelines, 2015.   MMWR Recomm Rep. 2015;64:1-137.Google Scholar
10.
Tamesis  RR , Foster  CS .  Ocular syphilis.   Ophthalmology. 1990;97(10):1281-1287. doi:10.1016/S0161-6420(90)32419-3PubMedGoogle ScholarCrossref
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