Photo Quiz

Red Eye and Aching in the Extremities


Am Fam Physician. 2020 Jun 15;101(12):755-756.

A 55-year-old woman presented with redness and pain in her right eye that had been present for one month (Figure 1). The pain began with a popping sensation, and the redness developed the next day. The pain was achy, located around the eye, and associated with watery discharge but no vision changes. One month earlier, she experienced mild achiness in her upper and lower extremities. She did not have fever, shortness of breath, skin rash, or other symptoms.

She had a history of hypertension, type 2 diabetes mellitus, mild nonproliferative diabetic retinopathy, bilateral glaucoma for which she had surgery three months earlier, and asthma. She was a former smoker. Her family history was positive for lupus erythematosus and rheumatoid arthritis

Physical examination revealed normal vital signs, upper and lower eyelids that were mildly tender to palpation, normal conjunctiva, and edema of the episcleral tissues and localized hyperemia of superficial episcleral vessels that were associated with nodular formation and clear discharge.




Based on the patient’s history and physical examination findings, which one of the following is the most likely diagnosis?

A. Conjunctivitis.

B. Episcleritis.

C. Herpetic keratitis.

D. Scleritis.

E. Uveitis.


The answer is B: episcleritis. Episcleritis is an acute, benign inflammation of the episclera, the thin vascular layer under the conjunctiva and superficial to the sclera. It presents as redness, discomfort, irritation, and watering of the eyes with preserved vision. It affects young or middle-aged women in 70% of cases.1,2 Episcleritis has simple and nodular forms. Less than one-third of cases are associated with systemic or inflammatory diseases.

Physical examination of patients with episcleritis may reveal local or diffuse dilatation of the episcleral vessels. Most cases are self-limited and resolve in two to three weeks.3 Severe symptoms may require nonsteroidal anti-inflammatory drugs or steroid eye drops.3 If episodes recur or the patient has symptoms of systemic illness, a workup should be performed to rule out rheumatoid arthritis, systemic lupus erythematosus, vasculitis, inflammatory bowel disease, or infectious diseases such as herpes or Lyme disease. It is important to differentiate benign episcleritis (no

Address correspondence to Nada Al-Hashimi, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Patel SJ, Lundy DC. Ocular manifestations of autoimmune disease. Am Fam Physician. 2002;66(6):991–998. Accessed April 16, 2020.

2. Pflipsen M, Massaquoi M, Wolf S. Evaluation of the painful eye. Am Fam Physician. 2016;93(12):991–998. Accessed April 16, 2020.

3. White GE. Episcleritis and scleritis. Optom Clin. 1991;1(4):79–87.

4. Harris KD. Herpes simplex virus keratitis. Home Healthc Now. 2019;37(5):281–284.

5. Rossi DC, Ribi C, Guex-Crosier Y. Treatment of chronic non-infectious uveitis and scleritis. Swiss Med Wkly. 2019;149:w20025.

6. Jabs DA, Mudun A, Dunn JP, et al. Episcleritis and scleritis: clinical features and treatment results. Am J Ophthalmol. 2000;130(4):469–476.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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