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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.1- 3 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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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 (email@example.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.
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