Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Necrotizing Scleritis
History of Present Illness
A 54-year-old Caucasian female with long-standing rheumatoid arthritis complains of severe right eye (OD) pain and redness for 1 week. The symptoms respond minimally to ibuprofen. She has had similar pain in both of her eyes in the past couple of years and was treated with topical corticosteroid drops and oral nonsteroidal antiinflammatory drugs (NSAIDs) by her ophthalmologist.
Her current medications include methotrexate 15 mg by mouth (PO) weekly, prednisone 7.5 mg PO daily, and ibuprofen 400 mg every 4 to 6 hours as needed ( Fig. 17.1 ).
Exam
| OD | OS | |
|---|---|---|
| Visual acuity | 20/100 | 20/20 |
| Intraocular pressure (IOP) | 14 | 14 |
| Sclera/conjunctiva | 3+ superior conjunctival injection with necrotic and avascular sclera | Diffuse scleral thinning nasally |
| Cornea | Moderate temporal haze without thinning | Clear |
| Anterior chamber (AC) | Trace cells | Deep and quiet |
| Iris | Unremarkable | Unremarkable |
| Lens | 1+ nuclear sclerosis (NS) and trace posterior subcapsular cataract (PSC) | 1+ NS |
| Anterior vitreous | Clear | Clear |
Questions to Ask
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How are your joint symptoms?
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Have you had any upper or lower respiratory tract problems, including nosebleed, sinus pain, or bloody sputum?
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Any pain in your earlobes?
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Any known kidney problem?
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Have you had ocular rosacea or severe blepharitis in the past?
She states that her rheumatoid arthritis has gradually worsened despite systemic therapy, the dose of which has remained the same for the past year. She denies upper respiratory tract or pulmonary symptoms. There is no known nephropathy.
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