Scleritis in Emergency Medicine Workup

Updated: Dec 31, 2018
  • Author: Theodore J Gaeta, DO, MPH, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Workup

Approach Considerations

The ED is the ideal location to initiate evaluation for collagen vascular disease, infection (conjunctival cultures), and immunocompetency. If scleritis is suspected, the emergency physician will contact an ophthalmologist. This would be a good opportunity to establish an evaluation and intervention plan. Getting the laboratory studies in the ED will save time for the patient and practitioners.

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Laboratory Studies

The diagnosis of scleritis is clinical. However, laboratory testing is often necessary to discover any associated connective tissue and autoimmune disease. Depending on the clinical suspicion, laboratory tests include, but are not limited to, the following:

  • Complete blood count (CBC) and electrolytes
  • Erythrocyte sedimentation rate (ESR)
  • Syphilis testing
  • Uric acid
  • Rheumatoid factor
  • Antinuclear antibody (ANA)

 

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Imaging Studies

B-scan ultrasonography may assist in detecting posterior scleritis. Ultrasonographic changes include scleral and choroidal thickening, scleral nodules, distended optic nerve sheath, fluid in Tenons capsule, or retinal detachment. [17]  

MRI or CT scans may play a role, but they should be ordered in consultation with an ophthalmologist. Chest radiography may be indicated to look for underlying pulmonary involvement arising from systemic disease. Imaging of sacroiliac joints is prudent when ankylosing spondylitis is suspected.

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Other Tests

Instillation of phenylephrine, a myd,iatic vasoconstrictor, helps differentiate deep scleral episcleral blood vessel involvement from superficial involvement; superficial vessels blanch following application of phenylephrine, while deeper vessels remain unaffected.

The Seidel test helps detect possible global perforation. Apply a moistened fluorescein strip over the entire surface of the eye while viewing under a slit lamp. If perforation exists, the fluorescein dye becomes diluted by the aqueous humor, appearing as a green dilute stream within the dark, concentrated, orange dye. Alternatively a Wood lamp may be used if a slit lamp is not available.

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