Red Eye Station

Presenting Complaint 

Harriet reports severe, painful redness in her left eye that started 3 days ago and has steadily worsened. She states — “It began as a dull ache, but now my eye is very painful and red. Bright lights really hurt, and moving my eye makes the pain much worse.”

Symptoms (SOCRATES)

• Site: left eye – “The pain is all around my left eye, especially at the front.”
• Onset: Subacute, over 3 days – “It started gradually three days ago and has been getting worse.”
• Character: Severe, deep, gnawing pain inside the eye– “It feels like a constant, deep ache behind my eye.”
• Radiation: No radiation to head or face – “The pain stays just in the left eye, it doesn’t spread anywhere else.”
• Associated symptoms: Redness, photophobia, mild blurred vision – “My eye is very red and bright lights really hurt.”
• Timing: Constant pain – “It never really goes away.”
• Exacerbating factors: Eye movements and bright light – “Moving my eye or going outside in daylight makes it much worse.”
• Relieving factors: Rest and covering the eye with a patch – “It feels a little better when I keep my eye closed.”
• Severity: Severe pain, 8/10 – “It’s very painful, I can hardly concentrate on anything else.”

Negative findings:

• No discharge or tearing – “There’s no sticky stuff or tears running down.”
• No trauma or injury – “I haven’t hurt my eye recently.”
• No headache or scalp tenderness – “I don’t have any headaches or tenderness around my head.”
• No double vision – “I don’t see double.”
• No changes to the right eye - “My right eye is completely fine.”
• Some joint pain and swelling in hands and knees – “I get occasional aches in my joints and muscles, particularly in my hands.”

Systemic Symptoms:

Fatigue: No 

Fever: No 

Night Sweats: No

Epistaxis or sinusitis: No 

Unintended Weight Loss: No 

Chest or Shoulder Tip Pain: No 

Shortness of Breath or Cough: No 

Peripheral Oedema: No 

Rashes or Skin Changes: No 

Headache: No

Change in Bowel Habits: No 

Urinary symptoms: No

Past Medical History

• Rheumatoid arthritis (diagnosed 5 years ago) – “I have rheumatoid arthritis which affects my hands and knees.”
• Hypertension – “I take medication for high blood pressure.”
• No previous eye conditions or surgeries – “I’ve never had any eye problems or operations before.” 

Drug History

• Methotrexate 15 mg weekly (oral) – “I take methotrexate once a week every Monday for my rheumatoid arthritis.”
• Folic acid 5 mg daily – “I take folic acid every day except Mondays to help with the methotrexate side effects.”
• Amlodipine 10 mg once daily – “I take amlodipine every morning for my blood pressure.”
• Occasional paracetamol 500 mg up to 3 times daily for joint pain – “I use paracetamol sometimes when my joints hurt.”

Allergies

• No known drug or food allergies.

Family History

• Mother: Has rheumatoid arthritis – “My mum has arthritis like me, mainly affecting her hands.”
• Father: Hypertension and type 2 diabetes mellitus – “My dad has high blood pressure and diabetes.”
• No family history of autoimmune eye diseases or scleritis – “None of my close relatives have had any eye autoimmune problems.”

Social history

• Lifestyle: Lives alone in a flat in a suburban area, office administrator for a local charity
• Activities & Hobbies: Enjoys gardening, reading historical novels, and yoga
• Smoking: Never smoked.
• Alcohol: Drinks socially, averaging 4-6 units per week – “I might have a glass of wine a couple of times a week.”
• Recreational Drugs: Never used 
• Exercise: Does yoga twice weekly and walks regularly

Ideas, Concerns, and Expectations:

• Ideas: “I think my eye pain might be something serious related to my arthritis.”
• Concerns: “I’m worried this pain means my arthritis is getting worse or spreading to my eye.”
• Expectations: “I want a clear explanation of what’s causing my eye pain and a thorough assessment.”

Observations:

- Respirations (Breaths/min): 15

- Oxygen Saturation (%): 99%

- Air or Oxygen: Air

- Blood Pressure (mmHg): 130/82

- Pulse (Beats/min): 88

- Consciousness (AVPU): A

- Temperature (Celsius): 36.5

NEWS Total Score: 0

Eye examination

Inspection

• Right eye: Normal appearance, no redness or swelling
• Left eye - show image below 

Image sourced from Kanski JJ, Bowling B. Clinical Ophthalmology: A Systematic Approach. 8th ed. Edinburgh: Elsevier; 2016.

• Left eye:
  • Marked deep scleral redness (violaceous hue), conjunctival injection present
  • Tender on palpation
  • If asked specifically: no blanching with topical phenylephrine, vessels not able to be moved with cotton-tipped applicator

Visual Acuity

• Right Eye (OD): 6/6 unaided
• Left Eye (OS): 6/12 with correction

Pupillary Reflexes

• Right eye (OD): Direct and consensual light reflexes normal
• Left eye (OS): Direct and consensual light reflexes normal
• Relative Afferent Pupillary Defect (RAPD): Absent

Swinging light test should be demonstrated or verbalised.

Visual Fields (by confrontation)

• Right Eye (OD): Full peripheral visual fields on confrontation
• Left Eye (OS): Full peripheral visual fields on confrontation

Eye Movements

• Right Eye (OD): Full range of movement without pain or restriction
• Left Eye (OS): Full range of movement but painful on all directions of gaze
• Patient reports discomfort when moving the left eye
• No diplopia present

Fundoscopy

• Right Eye (OD): Normal fundus appearance with clear optic disc and vessels, no signs of inflammation or retinal involvement
• Left Eye (OS): Mild optic disc hyperaemia with adjacent scleral vessel engorgement; no evidence of retinal detachment or vitreous haze

 Choose EITHER examiner viva questions OR patient communication questions

Communication Questions

1) “What is causing the pain and redness in my eye?”

2) “Is this condition serious? Could I lose my vision?”

3) “Is this my fault?”

4) “Are there any things I should avoid while I have scleritis?”

Exemplar answers

1) “The pain and redness are due to inflammation of the sclera, the white outer layer of your eye. This condition is called scleritis, and it can be very painful because the sclera has many nerve endings.”

2) “Scleritis is a serious condition that requires prompt treatment to reduce inflammation and prevent complications. If untreated, it can potentially affect your vision, so it’s important to follow up closely with your eye specialist.”

3) “No, scleritis is not caused by anything you did or didn’t do. Since you have rheumatoid arthritis, this can put you at increased risk. It’s not your fault, and the important thing is to focus on treatment and managing both conditions.”

4) “You should avoid rubbing your eyes and protect them from bright sunlight with sunglasses. Also, follow your doctor’s advice about medications and avoid any that might worsen inflammation.”

Examiner questions

1) What are the common risk factors and systemic diseases associated with scleritis?

• Underlying autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, granulomatosis with polyangiitis, relapsing polychondritis, inflammatory bowel disease
• Previous ocular trauma or surgery
• Infectious causes (less common)
• Middle-aged adults, more common in females

2) What are the typical clinical features of scleritis?

• Severe, deep, boring eye pain often worsening at night
• Can radiate to the scalp, jaw, ear or face
• Redness of the sclera, often diffuse or sectoral and violaceous in hue
• Tenderness on palpation of the globe
• Photophobia
• Reduced visual acuity if complications develop
• Possible associated signs: swelling, tearing
• Extraocular features of underlying autoimmune disease associated with scleritis

3) How would you differentiate scleritis from episcleritis on examination?

• Pain: Scleritis causes severe, deep pain; episcleritis is usually mild or absent
• Redness: Scleritis has a violaceous hue and deeper scleral vessel involvement; episcleritis shows bright red, more superficial vessels
• Tenderness: Scleritis is tender to touch; episcleritis is not usually tender
• Response to phenylephrine: Episcleritis vessels blanch with topical phenylephrine; scleritis vessels do not
• Response to cotton-tipped applicator: Scleral vessels cannot be moved with a cotton-tipped applicator, which differentiates inflamed scleral vessels from more superficial episcleral vessels
• Visual acuity: Usually preserved in episcleritis, may be reduced in scleritis

4) What investigations would you order in a patient presenting with scleritis?

• The diagnosis of scleritis is predominantly clinical, however investigations are required to diagnose underlying autoimmune or connective tissue disorders
• Blood tests: Full blood count, ESR, CRP, rheumatoid factor, anti-CCP antibodies, ANA, anti-dsDNA antibodies, ANCA
• Urinalysis to assess renal involvement if vasculitis suspected
• Imaging: Chest X-ray to screen for sarcoidosis or tuberculosis
• Referral for rheumatology assessment
• Infectious screen if suspected (e.g. syphilis serology, TB tests)
• Ocular ultrasound or MRI if posterior scleritis suspected

5) What is the initial management of scleritis?

• Prompt referral to ophthalmology
• Systemic non-steroidal anti-inflammatory drugs (NSAIDs) for mild cases
• Systemic corticosteroids for moderate to severe scleritis or if NSAIDs ineffective
• Immunosuppressive agents or biologics (e.g. methotrexate) if underlying autoimmune disease, inadequate control with corticosteroids or steroid-sparing needed
• Pain management with analgesics
• Regular follow up with ophthalmology/rheumatology

6) What complications can arise if scleritis is left untreated?

• Permanent vision loss due to complications such as cataract, glaucoma, or optic neuropathy
• Scleral thinning and perforation
• Secondary uveitis or keratitis
• Chronic ocular inflammation leading to scarring
• Systemic disease progression if underlying autoimmune condition untreated