Approach Considerations

The emergency department (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.

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
Serum uric acid
Rheumatoid factor
Antinuclear antibody (ANA)

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.^[22]

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.

Other Tests

Instillation of phenylephrine, a mydriatic 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.

Treatment & Management

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Author

Theodore J Gaeta, DO, MPH, FACEP Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, Society for Academic Emergency Medicine, Council of Residency Directors in Emergency Medicine, Clerkship Directors in Emergency Medicine, Alliance for Clinical Education

Disclosure: Nothing to disclose.

Coauthor(s)

Diana Valcich, MD Attending Physician, Department of Emergency Medicine, North Shore LIJ Hospital System

Diana Valcich, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gino A Farina, MD, FACEP, FAAEM Professor of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Jerome FX Naradzay, MD, Loice Swisher, MD, and Jonathan Adler, MD, to the development and writing of this article.