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(Part 2) Evaluation of the painful eye case study

By Clay Walker - Nov 04, 2020

Case Study: The Painful Eye 


Today, we will dive into the second part of our series with a patient case that I saw in clinic a few months ago. 

You can see the article we wrote about the painful eye part 1 here.

I had a 60-year-old patieent who presents with concerns of an extremely red and painful left eyem, along with surrounding eyebrow pain and tenderness to palpation. 

A red eye, as well as most ophthalmologic chief complaints, can be tough, especially in a family practice office where equipement for in-depth examination isn't always readily available.

Our patient today has a history of coronary artery disease, type 2 diabetes, severe COPD, hypertension, hyperlipidemia, and elevated liver enzymes. 

The patient reported that over the last few weeks that they noted clear eye drainage with extreme photophobia, and the eye and surrounding eyebrow being tender to touch.  The patient had no known eye injury or any foreign body or chemical exposure.


Painful Eye: History and Physical

When I first stepped into the exam room, I first saw that the patient was wearing their sunglasses.  Typically, when patients come into the clinic for eye complaints, they are not wearing their sunglasses. 

I removed the sunglasses to find that the patient’s sclera was entirely erythematous without any area of normal scleral whiteness.  As I examined the patient, the pupils were equal, round, and reactive to light and accommodation; however, there was considerable discomfort when shining light in the left eye.  No pain with consensual light reflex. 

Additionally, when the light was shined in the patient’s left eye, the eye rolled upwards in avoidance of photostimulation.  There was no warmth or swelling of the eye. 

Vital signs were normal in the office at that time, and the patient was afebrile.


My Initial Thoughts and Referral...

I thought to myself; this is not good.  This is not a run of the mill bacterial, viral, or allergic conjunctivitis, but something serious is going on.  I went back to my office and pulled out a lecture from PA School titled “The Red Eye” (Thanks, Laurie!). 

As I read through and looked at the images in comparison to my patient’s presentation, I was concerned about episcleritis versus scleritis, severe conjunctivitis, or acute glaucoma.  I immediately got on the phone and contacted the local optometrist who was able to see the patient in office the same day, and a referral to ophthalmology the next day was made. 

Later in the afternoon I received a call from the optometrist who noted that the patient’s examination was most consistent with nodular scleritis, and the patient was started on a short course of naproxen and prednisolone ophthalmic drops.

At that time, I was unsure what could have caused the patient’s nodular scleritis to arise.  I began to research the disease and found the association between systemic autoimmune/rheumatologic and infectious diseases that can lead to a disease manifesting with ocular symptoms such as nodular scleritis.


The Workup Behind Eye Pain

I started off ordering laboratory testing including a complete blood count, comprehensive metabolic panel, urinalysis with microscopic evaluation, sedimentation rate, TSH, and C-reactive protein. 

In addition, I ordered a rheumatoid factor, anti-cyclic citrullinated antibodies, p-ANCA, c-ANCA, ANA with reflex, Lyme antibodies, ACE level, and an RPR.

Initially, the screening laboratory results returned first which showed non-acute findings on the CBC, CMP, TSH, UA, and ESR.  The CRP was slightly elevated.

The following days the more specific lab results returned which revealed negative findings on the RF, anti-CCP antibodies, c-ANCA, ANA with reflex, ACE level, and RPR.  However, that same day the concerning results were received; a borderline positive p-ANCA titer at 1:20 and Lyme IgM and PR-3 antibodies were elevated.

We contacted the patient and aksed if they had any rash or recalled any tick bites; the patient however denied any of it.  The patient was started on oral doxycycline urgently referred to rheumatology. 

The following week the patient was seen by rheumatology who noted that the p-ANCA level being borderline was not elevated enough to be worrisome of systemic vasculitis such as granulomatosis with polyangiitis (formerly Wegener’s disease); however, the exam and laboratory results were diagnostic for acute Lyme disease manifesting as Lyme disease related Scleritis.

Nodular anterior Scleritis

The rheumatologist immediately referred the patient to ophthalmology where the patient was seen the same afternoon.  The ophthalmologist continued the prednisolone ophthalmic drops, but also started oral prednisone as well.


Lyme Disease

Lyme Disease may present with rash, fatigue, joint pain, myalgia, palpitations, chest pain, headaches, altered mental status, neuropathy, and cranial nerve palsies.

Ocular manifestation of Lyme disease may include conjunctivitis, keratitis, scleritis, retinal vasculitis, iridocyclitis, uveitis, choroiditis, or optic neuropathy. 

Conjunctivitis associated with Lyme disease is the most common ocular manifestation occurring in around ten percent of cases.1  The remaining ocular manifestations mentioned above are rare and are only described in case reports where confirmation of Borrelia burgdorferi was constrained.1

Just as with our patient in this case, scleritis will present with an underlying rheumatologic or infectious disease etiology over 50 percent of the time.  Patients will often present with severe penetrating pain in the affected eye with radiation into the brow, forehead, jaw, or sinuses. 

Other things that the patient may note is worsening pain with touch over the globe, excessive tearing, photophobia, blurred vision, and awakening during the night due to pain.  This diagnosis warrants an urgent referral to ophthalmology as well as rheumatology for the treatment of underlying systemic disease.

I hope you all enjoyed today’s compelling case on a rare etiology of a red eye.  As you can see not all red eyes are the same, and some etiologies such as conjunctivitis can be treated with eye drops and sent home, whereas others need acute immediate evaluation as seen above.  Always remember to stay vigilant and be a lifelong learner in medical education and clinical practice.  Until next time!


  1. UpToDate. Clinical Manifestations of Lyme Disease in Adults. Accessed: September 10, 2018.
  2. UpToDate. Clinical Manifestations and Diagnosis of Scleritis. Accessed: September 10, 2018.
  3. UpToDate. Treatment of Scleritis. Accessed: September 10, 2018.
  4. The Red Eye and PANCE Review by Laurie Ryznyk, MPAS, PA-C, DFAAPA. Southern Illinois University School of Medicine Physician Assistant Program. May 2016.


This article, blog, or podcast should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony.  No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.