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JAMA Ophthalmology Clinical Challenge
March 2018

A Painful Red Eye

Author Affiliations
  • 1Department of Ophthalmology, University of California, San Francisco
  • 2Department of Ophthalmology, San Francisco Veterans Affairs Medical Center, San Francisco, California
JAMA Ophthalmol. 2018;136(3):299-300. doi:10.1001/jamaophthalmol.2017.4167

A 63-year-old white man with a history of cigarette use (≥80 pack-years) and alcohol dependence presented to the ophthalmology clinic with several weeks of left eye pain and redness. A review of systems was remarkable for unintentional weight loss, night sweats, and cough with scant sputum. On presentation, best-corrected visual acuity was 20/20 OU. Intraocular pressure, pupillary reaction, and ocular motility were normal. The right eye had normal anterior and posterior segment examination findings. The left eye was notable for mostly superior conjunctival and scleral hyperemia with dilated scleral vessels and associated scleral thinning with a conjunctival epithelial defect (Figure 1). The results of posterior examination of the left eye were normal. Results of serologic tests, including Treponema pallidum particle agglutination assay, HIV, hepatitis B and C, Lyme antibody, rheumatoid factor, and anticyclic citrullinated peptide, were negative. Angiotensin-converting enzyme level, uric acid level, erythrocyte sedimentation rate, complete blood cell count, and basic metabolic panel results were within normal limits. The results of proteinase 3–antineutrophil cytoplasmic antibody (ANCA) testing and interferon γ release assay using QuantiFERON-TB gold (QFT) (Qiagen) were positive. Chest computed tomography revealed tiny, scattered solid pulmonary nodules that were too small to characterize according to the radiology department. The patient was referred to the infectious diseases clinic, where the results of sputum culture and polymerase chain reaction for Mycobacteria tuberculosis were negative. Pulmonology evaluation determined that the pulmonary nodules were too small for biopsy via bronchoscopy.