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Right eye

Left eye

Photos courtesy of: Mamta Agarwal, Sankara Nethralaya, India
Used with permission. Not to be reproduced.

A 40-year-old lady presented with complaints of recurrent attacks of pain and redness in both eyes for the last eight months. Her pain radiated to the forehead, brow and jaw. Systemic history revealed on and off fever, malaise, and joint pains for two years. She was treated with topical steroids and oral nonsteroidal anti-inflammatory drugs (NSAID) elsewhere. Her best corrected visual acuity was 6/6 in both eyes. Slit lamp biomicroscopy in both eyes was as shown above. Fundus examination was within normal limits.

1.	What is the clinical diagnosis?
	c -- necrotizing anterior scleritis The clinical photos show bilateral injection of scleral and deep episcleral vessels as well as areas of thinning with increased visibility of underlying uveal tissue. Laboratory tests revealed erythrocyte sedimentation rate (ESR) – 84 mm in the first hour, cANCA +ve. Chest X-ray showed pulmonary infiltrates. A diagnosis of Wegener’s granulomatosis was made.       Scleritis occurs more commonly in females than in males with a peak incidence in the fourth to sixth decades. It is bilateral in 50% of cases. This clinically presents as severe, deep boring eye pain which may radiate to the ipsilateral side of the head or face. Nearly 50% of patients with scleritis have an associated systemic disease (rheumatoid arthritis, Wegener’s granulomatosis, relapsing polychondroitis, Reiter’s syndrome, systemic lupus eryathematosis). It can be classified as follows: Anterior scleritis Diffuse anterior Nodular anterior Necrotizing With inflammation Without inflammation (scleromalacia perforans) Posterior scleritis It can be associated with corneal changes (peripheral keratitis, limbal guttering, keratolysis), glaucoma, uveitis and cataract. Treatment includes oral nonsteroidal anti-inflammatory drugs (NSAIDS), corticosteroids, and immunosuppressives.
2.	Which of the following statements is false?
	d -- Episcleritis is seen in older patients and is always associated with collagen vascular diseases.