eye redness!! photo please see.

[Neil1758]

Hi there,

I've posted before on here under the topic "Eye problem 9 months now". So you probably know my situation I thought I would post a picture of my eye on here to show the redness. My doctors don't seem concerned at all about this which is strange.

When I touch my eye its extremely sore and there is a constant pain in my eyes which never go away. Can you please tell me i'm not going crazy and there is definitley something not quite right here with my eye.

Thanks.
Neil.

[Neil1758]

Hi there,

Recently I have been having a new symptom where the light flickers from my left eye. When I focus on something like a computer screen or a light it visibly flickers it used to do this every so often so I wasn't worried now it does it almost all the time.

Please Can you help me and tell me what this may be? what should I tell my doctor next time I see him. At the moment they are not concerned. This really really worries me.

I would really appreciate any advice.

Thanks
Neil.

[John C Hagan III, MD, FACS, FAAO]

Best of luck. JCH

[Neil1758]

Thank you for all your help.

[John C Hagan III, MD, FACS, FAAO]

Good luck, if you go private and its your money then you can seek out the proper type of ophthalmologist Eye MD: cornea-external disease ophthalmologist.
JCH MD

[Neil1758]

thanks for the advice.

I did ask my General practioner about it and he said there was no one who specialises in my problem. He said most specialise in cataracts which isn't very good. When I was at the eye hospital the other day I also asked if I should go private but the doctor said it's not worth it as you will end up seeing the same doctors that you have seen already.

One other thing the redness on my eye is worse in the evening but when I wake up in the morning its not really that bad its still there but not as bad as that pic. Does this mean it could still be episcleritis or scleritis? The nurse told me that the eye would be look as bad as that picture I showed you all the time if I had scleritis. My eye does get this red every night but just not in the morning.

Very concerned here. They just don't seem to care! I think I am going to have to consider treatement elsewhere.

[John C Hagan III, MD, FACS, FAAO]

Unless you are a multi-millionaire it would not be worth the expense of flying to the USA for consultation and treatment. Besides the problem is often persistent or recurrent and you need a Eye MD ophthalmologist ideally a cornea-external disease specialist that you can get easily to.  It would be much easier to see such a specialist under a "private pay". I am told they do a booming business because of experiences like yours.

JCH MD

[Neil1758]

Hi there,

Went to the eye hospital yesterday they told me that they don't know why my eye is red and can't see any signs of scleritis. I also showed them the picture of my eye they weren't much help to be honest and didn't seem interested in me. the nurse told me that if I had scleritis I wouldn't be able to talk I would be in that much pain, I am in a huge amount of pain its sore all the time and the pain extends to the eyebrows and around the eye and feels like swelling. After 9 months they still haven't come to any conclusion.

I don't think they know what's going on with my eyes. I'm pretty worried now. The medication I have tried so far is TB meds for 6 months as they suspected that was the cause but it wasn't. I have also tried flurbiprofen and corticosteroids for 6 weeks which helped a little with the pain but not a significant deal. Is there anything I should ask my doctor to try? I'm really concerned any advice would be appreciated.

I also have another question are people from UK able to get treated in America by paying? if so how much is the rough cost for a consultation.

Thanks.
Neil.

[John C Hagan III, MD, FACS, FAAO]

Neil:  This delay in dealing with your problem is inexcusible. If at all possible consider a private specialist. Otherwise try and raise as much fuss as you can to get things moving.

I am posting part of an article on Eye (Ophthalmic) manifestations of rheumatic disease. It is from the Jan/Feb 2012 issue of Missouri Medicine: the Journal of the Missouri State Medical Association and is copyrighted. I am the editor of that peer-reviewed medical journal. I hope it will be helpful to you and others. The authors are on the Staff of the University of Missouri School of Medicine in Columbia, Missouri, USA.  Note especially the section on episcleritis and sclerits. There are other possible causes within the eye.


Ophthalmic Manifestations of Rheumatologic Disease:  Diagnosis and Management

Carisa K. Petris, M.D., Ph.D., and Arghavan Almony, M.D.

Subtitle:   A low threshold for ophthalmologic consultation should exist when evaluating and treating a diversity of rheumatologic disease.


Abstract
Rheumatologic diseases are often associated with ophthalmic findings.  Familiarity with and recognition of these ophthalmic presentations are important in the management of both the systemic and ocular manifestations of the disease. Identification of ocular signs and symptoms of rheumatologic disease will allow a more comprehensive approach to treatment of patients with rheumatic conditions.
Introduction

The eye is an important indicator of rheumatologic disease. A wide variety of ophthalmic clinical manifestations exist including inflammation of the cornea, conjunctiva, lacrimal gland, episclera, sclera, uvea (including anterior, intermediate, and posterior uveitis), and ophthalmic blood vessels. The most common presenting signs of inflammation of these structures include pain, photophobia, decreased vision, burning, itching, watering (epiphora), and redness. Various ocular signs and symptoms are characteristic of different rheumatologic diseases (Table 1). The ophthalmic manifestations as well as diagnosis and management of each condition will be discussed in this review. Additionally, ophthalmic screening for a variety of medications used to treat rheumatic disease will be outlined.

Uveitis
The uvea is the middle, pigmented layer of the eye that consists of vascular structures including the iris, ciliary body, and choroid (Figure 1). Inflammation of the uvea is referred to as uveitis, the etiology of which is classified into infectious or autoimmune causes.
Episcleritis and Scleritis
Episcleritis is generally a benign, self-limited inflammation of the episcleral tissues associated with segmental (70%) or diffuse (30%) episcleral redness that is bright red or salmon pink (Figure 2)27. There may be unilateral or bilateral involvement and a simple or nodular appearance. Unlike deeper scleral vessels, episcleral vessels blanch with 2.5% topical phenylephrine. It is usually found in patients 20-50 years of age and is associated with mild ocular discomfort or tenderness. The work-up for an underlying rheumatologic association (i.e. Sjogren’s syndrome, rheumatoid arthritis or gout) is usually unnecessary except after multiple episodes. Artificial tears and NSAIDs are the mainstay of treatment. Rarely, a short course of topical corticosteroids is warranted.28, 29
Scleritis often occurs in patients in the fourth to sixth decades of life and is rare in children. Compared to episcleritis there is a much more severe inflammation of the deeper scleral vessels which often presents with severe, deep boring pain which may be referred to the head or face. There may also be a violaceous hue of the inflamed sclera and criss-crossing of deep vessels with associated scleral and episcleral edema noted with slit-lamp biomicroscopy.  Scleritis is caused by immune-mediated vasculitis leading to the destruction of the sclera and is often associated with an underlying autoimmune condition such as rheumatoid arthritis, vasculitis, inflammatory bowel disease, relapsing polychondritis, psoriatic arthritis, Behçet’s disease, and Wegener’s granulomatosis. An underlying autoimmune association may be found in up to is found in up to 50% of patients.30, 31, 32 Annual work-up is indicated in those individuals whose initial evaluation negative.28, 33 There is no evidence of autoimmunity at this point; however, scleral biopsies show immune complex deposition and neutrophil invasion of vessels, generalized MHC class II expression, and T cell and macrophage infiltration.34 Scleral thinning is thought to be secondary to matrix metalloproteinase (MMP) secretion by plasma cells, cytotoxic T cells, and macrophages.
Necrotizing scleritis with inflammation typically presents with severe pain and a localized patch of scleral inflammation. Over time the sclera will thin and produce a blue-gray appearance due to the visibility of the underlying choroid. Necrotizing scleritis without inflammation is a distinct form of anterior scleritis with minimal pain known as scleromalacia perforans. In this condition, the sclera is thin and the underlying dark uveal tissue becomes apparent. Spontaneous perforation is rare but the eye may rupture with minimal trauma.
Nearly 60% patients with scleritis will need oral corticosteroids or immunosuppressive drugs to control the disease. Treatment of non-necrotizing diffuse scleritis is initiated with ibuprofen 600 mg three times daily. Occasionally, topical corticosteroids may also reduce ocular inflammation in mild cases. Severe nodular disease and necrotizing disease in rheumatoid arthritis-associated scleritis almost always requires initiation of oral corticosteroids followed by tumor necrosis factor (TNF) inhibitors such as infliximab (Remicade). Subconjunctival corticosteroids may also be effective in reducing scleral inflammation but are generally contraindicated due to scleral necrosis and exacerbation of epithelial defects. Treatment failure may be defined as progression to a more severe form or lack of response in 2-3 weeks, and warrants initiation of alternative treatment.  Corticosteroids given orally or in high dose pulsed treatments may be effective. Systemic immunosuppressive therapy with methotrexate, cyclosporine or cyclophosphamide is recommended for treatment failure. Those with rheumatoid arthritis are generally placed on methotrexate whereas those with active vasculitic disease (i.e. Wegener’s granulomatosis) are prescribed cytotoxic agents (i.e. cyclophosphamide).35, 28

[Neil1758]

Hi thanks so much for your reply. At least I know I'm not going crazy I've seen quite a few eye doctors in the NHS but none of them are concerned about it. my vision is blurry and my eye is in extreme pain. It seems like no doctors are listening to me. This problem has been going on for 9 months now.

My symptoms sound quite similar to episcleritis. What tests should I request from my Doctor to diagnose Episcelritis? I'm quite concerned now about my eye. I will try and make an appointment as soon as possible. The process is very slow over here in the U.K.

Thanks
Neil.

[John C Hagan III, MD, FACS, FAAO]

I would be very concerned about an eye that looked like that. It could be episcleritis possibly associated with a systemic disease; could by hyperthyroid eye disease; could even represent problems with blood vesses in, around or behind the eye.

If you are unable to get to see a ophthalmologist Eye MD with a specialty in cornea/external disease through the ponderous NHS then you may need to consult a private ophthalmologist. The appearance of you eye is very concerning. Keep fighting the system and don't be put off.

JCH MD