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OP5.1-2 | Sclera — Graded Quiz
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A 32-year-old woman presents with acute onset of mild redness and discomfort in the right eye. There is no photophobia or significant pain. Slit-lamp examination shows sectoral bright-red injection confined to the superficial layers. Phenylephrine 2.5% drops cause complete blanching within 60 seconds. Which management plan is most appropriate?
Correct. Phenylephrine blanching confirms episcleritis — a self-limiting condition managed with lubricants and oral NSAIDs as needed. Systemic work-up is not routinely required unless symptoms recur frequently or a systemic disease is suspected.
Episcleritis confirmed by phenylephrine blanching is self-limiting. First-line management is supportive (lubricants, cool compresses). Oral NSAIDs are added for discomfort. Systemic work-up and rheumatology referral are not routinely required for episcleritis.
Incorrect. Complete phenylephrine blanching is diagnostic of episcleritis, which is self-limiting and does not require systemic steroids, urgent rheumatology referral, or antifungal treatment. Lubricants with oral NSAIDs as needed is the appropriate first-line plan.
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On the Watson-Hayreh classification of scleritis, which subtype carries the WORST visual prognosis and highest risk of globe perforation?
Correct. Necrotising scleritis is the most severe subtype with the worst visual prognosis. Progressive scleral destruction can lead to uveal prolapse and globe perforation. It demands urgent systemic immunosuppression.
Necrotising scleritis with inflammation (formerly Necrotising scleritis) carries the worst ocular prognosis — progressive scleral thinning, uveal show, and risk of perforation. It is most strongly associated with severe systemic vasculitis (RA, GPA).
Incorrect. Diffuse and nodular anterior scleritis have a relatively better prognosis. Necrotising scleritis with inflammation is the most destructive subtype, with highest risk of scleral thinning and perforation, and strongest systemic disease associations.
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A 52-year-old man with scleritis is found to be c-ANCA positive. Urine microscopy shows red cell casts. What is the most critical immediate action?
Correct. c-ANCA positivity with red cell casts signals GPA nephritis — a potentially fatal complication requiring immediate multidisciplinary referral. This is the classic haematuria trap: never defer referral when scleritis is ANCA-positive with urinary findings.
ANCA-positive scleritis with haematuria (red cell casts) = granulomatosis with polyangiitis with active glomerulonephritis — a life-threatening combination. Urgent nephrology and rheumatology referral is mandatory. This is the haematuria trap taught in the SDL.
Incorrect. This combination — c-ANCA positive scleritis + red cell casts — represents granulomatosis with polyangiitis with active glomerulonephritis. This is a medical emergency requiring urgent nephrology and rheumatology referral, not expectant management.
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A patient with recurrent bilateral scleritis has no joint symptoms. Laboratory work-up reveals positive c-ANCA, elevated ESR, and anaemia of chronic disease. Chest X-ray shows pulmonary nodules. Which systemic diagnosis is most likely?
Correct. The combination of c-ANCA, pulmonary nodules, and scleritis is the defining presentation of GPA. Renal function and urine microscopy must be checked urgently for glomerulonephritis.
c-ANCA positivity plus pulmonary nodules plus scleritis is the classic triad pointing to GPA (Wegener granulomatosis). SLE is ANA/anti-dsDNA positive. Ankylosing spondylitis causes anterior uveitis, not typically scleritis. Sarcoidosis may cause scleritis but is p-ANCA negative.
Incorrect. The triad of c-ANCA positivity, pulmonary nodules, and scleritis is highly specific for granulomatosis with polyangiitis (GPA). SLE is associated with ANA/anti-dsDNA, and ankylosing spondylitis more typically causes anterior uveitis.
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Scleromalacia perforans is the end-stage of which scleral condition?
Correct. Scleromalacia perforans = necrotising scleritis without inflammation, pathognomonic of long-standing RA. Despite minimal pain, it leads to progressive scleral destruction and risk of globe perforation.
Scleromalacia perforans is necrotising scleritis without inflammation — characterised by painless progressive scleral thinning and uveal show, occurring almost exclusively in long-standing rheumatoid arthritis. It is paradoxically the most visually destructive form yet the least symptomatic.
Incorrect. Scleromalacia perforans is necrotising scleritis without inflammation — almost exclusively seen in long-standing rheumatoid arthritis. It is painless but progressive, with scleral thinning and uveal show that can lead to perforation.
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Which of the following systemic conditions is typically associated with episcleritis rather than scleritis?
Correct. IBD is a recognised systemic association of episcleritis. By contrast, GPA, severe RA, relapsing polychondritis, and systemic vasculitides are associated with scleritis — the more severe and vision-threatening condition.
IBD (Crohn disease, ulcerative colitis) and rosacea are more commonly associated with episcleritis (milder systemic associations). GPA, RA, relapsing polychondritis, and polyarteritis nodosa are the classic scleritis associations. This distinction matters for work-up intensity.
Incorrect. GPA, severe RA, and relapsing polychondritis are systemic associations of scleritis. IBD (Crohn disease, ulcerative colitis) is more typically associated with episcleritis, which carries a milder systemic association profile than scleritis.
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